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Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes (PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy. Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health–sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure. One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits ≤ 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P <.001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P <.001) and 17.1% (P <.001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P =.02) and 26.4% (P =.001) worse, respectively, than mean preoperative levels. Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days. [ABSTRACT FROM AUTHOR]

Patient-reported outcomes (PROs) assessment is a necessary component of surgical outcome assessment and patient care. This study examined the success of routine PROs assessment in an academic-based thoracic surgery practice. PROs, measuring pain intensity, physical function, and dyspnea, were routinely obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System (PROMIS) on all thoracic surgery patients beginning in April 2018 through January 2021. Questionnaires were administered electronically through a web-based platform at home or during the office visit. Completion rates and barriers were measured. A total of 9725 thoracic surgery office visits occurred during this time frame. PROs data were obtained in 6899 visits from a total of 3551 patients. The mean number of questions answered per survey was 22.4 ± 2.2. Overall questionnaire completion rate was 65.7%. A significant decline in survey completion was noted in April 2020, after which adjustments were made to allow for questionnaire completion through a mobile health platform. Overall monthly questionnaire completion rates ranged from 20% (April 2020) to 90% (October 2018). Mean T scores were dyspnea, 41.6 ± 12.3; physical function, 42.7 ± 10.5; and pain intensity, 52.8 ± 10.3. PROs can be assessed effectively in a thoracic surgery clinic setting, with minimal disruption of clinical activities. Future efforts should focus on facilitating PROs collection from disadvantaged patient populations and scaling implementation across programs. [ABSTRACT FROM AUTHOR]

Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training. After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation. After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein. Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development. [ABSTRACT FROM AUTHOR]

Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database (GTSD) are limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes. We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural-Urban Continuum Codes to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission. Zip codes were included in 47.2% of patients. Zip-coded patients were older, were more comorbid, had less advanced disease, and were more commonly treated with minimally invasive approaches than were those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all 3 major endpoints. Community size, based on Rural-Urban Continuum Codes coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints. Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared with sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes. [ABSTRACT FROM AUTHOR]

Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient-reported outcomes (PROs) provide valuable insight into the patient experience and allow measurement of preoperative and postoperative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally invasive lung cancer surgery. PRO surveys assessing physical function and pain intensity were conducted using instruments from the National Institutes of Health Patient-Reported Outcomes Measurement Information System. PRO surveys were administered to patients undergoing minimally invasive lung cancer resections at preoperative, 1-month, and 6-month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time. A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67 ± 9.6 years, 43% were male, and 80% were White. When comparing clinical variables with PRO scores after surgery, lower diffusing capacity of the lungs for carbon monoxide (D lco) was associated with significantly worse physical function (P <.01) and greater pain intensity scores (P <.01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores. Low preoperative D lco was associated with significant decreases in PRO after minimally invasive lung cancer surgery. D lco may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision making. [ABSTRACT FROM AUTHOR]

Background Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Methods The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost. Results A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications. Conclusions Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs. [ABSTRACT FROM AUTHOR]

Background We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection. Methods A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032–z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher’s exact test. Multivariate analysis was performed using a linear regressions model. Results A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay. Conclusions Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients’ excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients. [ABSTRACT FROM AUTHOR]

Background A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations. Methods The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection. Results The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline. Conclusions Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies. [ABSTRACT FROM AUTHOR]

Background Data regarding risk factors for readmissions after surgical resection for lung cancer are limited and largely focus on postoperative outcomes, including complications and hospital length of stay. The current study aims to identify preoperative risk factors for postoperative readmission in early stage lung cancer patients. Methods The National Cancer Data Base was queried for all early stage lung cancer patients with clinical stage T2N0M0 or less who underwent lobectomy in 2010 and 2011. Patients with unplanned readmission within 30 days of hospital discharge were identified. Univariate analysis was utilized to identify preoperative differences between readmitted and not readmitted cohorts; multivariable logistic regression was used to identify risk factors resulting in readmission. Results In all, 840 of 19,711 patients (4.3%) were readmitted postoperatively. Male patients were more likely to be readmitted than female patients (4.9% versus 3.8%, p < 0.001), as were patients who received surgery at a nonacademic rather than an academic facility (4.6% versus 3.6%; p = 0.001) and had underlying medical comorbidities (Charlson/Deyo score 1+ versus 0; 4.8% versus 3.7%; p < 0.001). Readmitted patients had a longer median hospital length of stay (6 days versus 5; p < 0.001) and were more likely to have undergone a minimally invasive approach (5.1% video-assisted thoracic surgery versus 3.9% open; p < 0.001). In addition to those variables, multivariable logistic regression analysis identified that median household income level, insurance status (government versus private), and geographic residence (metropolitan versus urban versus rural) had significant influence on readmission. Conclusions The socioeconomic factors identified significantly influence hospital readmission and should be considered during preoperative and postoperative discharge planning for patients with early stage lung cancer. [ABSTRACT FROM AUTHOR]

Background Proposed changes in health care will place an increasing burden on surgeons to care for patients more efficiently to minimize cost. We reviewed costs surrounding video-assisted thoracoscopic surgery (VATS) lobectomies to see where changes could be made to ensure maximum value. Methods We queried The Society of Thoracic Surgeons database for all VATS lobectomies performed for lung cancer from January 2011 to December 2013. Clinical data were linked with hospital financial data to determine hospital expenditures for each patient. Results In all, 263 VATS lobectomies were included. Mean operating room time was 236 minutes, and median length of stay was 4 days. Mean hospital cost was $19,769. The majority of cost (58%) was attributed to operating room and floor costs (length of stay), and the majority of operating room costs were secondary to room rate and staplers. A total of 77 complications, as defined by STS, occurred in the cohort; 41 patients had only one complication, 11 patients had two complications, and 6 patients had three or more complications. The occurrence of one complication was associated with a net loss of $496 whereas two complications in a patient led to a $3,882 net loss. Overall, complications were independently correlated with significant cost increases. Conclusions Our study shows that the most significant costs associated with VATS lobectomies relate to operating room time, stapler use, floor charges, and cost associated with complications. Cost-reducing strategies will need to concentrate on optimizing operating room times and reducing length of stay while simultaneously minimizing complications. [ABSTRACT FROM AUTHOR]

Background Patients with early stage lung cancer considered high risk for surgery are increasingly being treated with nonsurgical therapies. However, consensus on the classification of high risk does not exist. We compared clinical outcomes of patients considered to be high risk with those of standard-risk patients, after lung cancer surgery. Methods A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by ACOSOG z4032/z4099 criteria: major: forced expiratory volume in 1 second (FEV 1 ) 50% or less or diffusing capacity of lung for carbon monoxide (D lco ) 50% or less; and minor: (two of the following), age 75 years or more, FEV 1 51% to 60%, or D lco 51% to 60%. Demographics, perioperative outcomes, and survival between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the χ 2 test/Fisher’s exact test and the t test/Mann-Whitney U test. Survival was studied using a Cox regression model to calculate hazard ratios, and Kaplan-Meier survival curves were drawn. Results In all, 180 patients (37%) were classified as high risk. These patients were older than standard-risk patients (70 years versus 65 years, respectively; p < 0.0001) and had worse FEV 1 (57% versus 85%, p < 0.0001), and D lco (47% versus 77%, p < 0.0001). High-risk patients also had more smoking pack-years than standard-risk patients (46 versus 30, p < 0.0001) and a greater incidence of chronic obstructive pulmonary disease (72% versus 32%, p < 0.0001), and were more likely to undergo sublobar resection (32% versus 20%, p = 0.001). Length of stay was longer in the high-risk group (5 versus 4 days, p < 0.0001), but there was no difference in postoperative mortality (2% versus 1%, p = 0.53). Nodal upstaging occurred in 20% of high-risk patients and 21% of standard-risk patients ( p = 0.79). Three-year survival was 59% for high-risk patients and 76% for standard-risk patients ( p < 0.0001). Conclusions Good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In our study, surgery led to upstaging in 20% of patients and acceptable 1-, 2-, and 3-year survival as compared with historical rates for nonsurgical therapies. This study suggests that empiric selection criteria may deny patients optimal oncologic therapy. [ABSTRACT FROM AUTHOR]

Background Hospital readmissions are costly and associated with inferior patient outcomes. There is limited knowledge related to readmissions after esophagectomy for malignancy. Our aim was to determine the impact on survival of readmission after esophagectomy. Methods This cohort study utilizes Surveillance, Epidemiology, and End Results–Medicare data (2002 to 2009). Survival, length of stay, 30-day readmissions, and discharge disposition were determined. Multivariate logistic regression models were created to examine risk factors associated with readmission. Results In all, 1,744 patients with esophageal cancer underwent esophagectomy: 80% of patients (1,390) were male, and mean age was 73 years; 71.8% of tumors (1,251) were adenocarcinomas, and 72.5% (1,265) were distal esophageal tumors; 38% of patients (667) received induction therapy. Operative approach was transthoracic in 52.6% of patients (918) and transhiatal in 37.4% (653), and required complex reconstruction (intestinal interposition) in 9.9% (173). Stage distribution was as follows: stage I, 35.3% (616); stage II, 32.5% (566); stage III, 27.9% (487); and stage IV, 2.3% (40). Median length of stay was 13 days, hospital mortality was 9.3% (158 patients), and 30-day readmission rate was 18.6% (212 of 1,139 home discharges); 25.4% of patients (443) were discharged to institutional care facilities. Overall survival was significantly worse for patients who were readmitted ( p < 0.0001, log rank test). Risk factors for readmission were comorbidity score of 3+, urgent admission, and urban residence. Conclusions Hospital readmissions after esophagectomy for cancer occur frequently and are associated with worse survival. Improved identification of patients at risk for readmission after esophagectomy can inform patient selection, discharge planning, and outpatient monitoring. Optimization of such practices may lead to improved outcomes at reduced cost. [ABSTRACT FROM AUTHOR]

Background. Intrapyloric botulinum toxin injection has emerged as a possible alternative to standard pyloric drainage procedures. Possible advantages include decreased operative time and less postoperative dumping and bile reflux symptoms. However, data are lacking to show its effectiveness versus standard drainage procedures. The purpose of this review is to compare the results in a prospective cohort of patients who received pyloric botulinum injection versus patients who received pyloromyotomy or pyloroplasty with esophagectomy. Methods. We performed a retrospective review of a prospective database of all patients who underwent an open esophageal resection at a single institution from 2005 through 2010. Three hundred twenty-two patients were divided into 3 groups for analysis: botulinum injection (n = 78), pyloromyotomy (n = 45), and pyloroplasty (n = 199). We compared these groups with respect to duration of the procedure, presence of delayed gastric emptying on postoperative swallow studies, requirement of anastomotic dilation, requirement of pyloric dilation, use of postoperative promotility agents, and patient experience of postoperative symptoms of reflux or dumping, or both. Results. Patients receiving botulinum injections experienced similar delayed gastric emptying on postoperative radiologic evaluation as did patients undergoing pyloromyotomy and pyloroplasty (16% versus 5% and 13%, respectively; p = 0.14). Mean operative time was significantly shorter for the patients receiving botulinum as expected (239 minutes versus 312 minutes and 373 minutes, respectively; p < 0.001). However, more patients receiving botulinum and pyloric dilation (22% versus 4% and 2%, respectively; p < 0.001) experienced postoperative reflux symptoms (32% versus 12% and 13%, respectively; p = 0.001) and used postoperative promotility agents (22% versus 5% and 15%, respectively; p = 0.04). There was no statistical difference between the groups regarding postoperative dumping. Conclusions. Use of intrapyloric botulinum injection significantly decreased operative time. However, the patients receiving botulinum experienced more postoperative reflux symptoms, had increased use of promotility agents as well as a requirement for postoperative endoscopic interventions, and postoperative dumping was not reduced by the reversible procedure. Intrapyloric botulinum injection should not be used as an alternative to standard drainage procedures. Pyloromyotomy appears to be the drainage procedure of choice to accompany an esophagectomy. [ABSTRACT FROM AUTHOR]

Background. The advent of high-resolution computed tomography scanning and increase in use of chest imaging for high-risk patients has led to an increase in the identification of small pulmonary nodules. The ability to locate and remove these nodules through a thoracoscopic approach is difficult. The purpose of this study is to report our experience with fiducial localization and percutaneous thoracoscopic wedge resection of small pulmonary nodules. Methods. This is a retrospective analysis of our patients who underwent computed tomography-guide fiducial localization of pulmonary nodules. Nodules were identified with intraoperative fluoroscopy and remove by thoracoscopic wedge resection. Results. Sixty-five nodules were removed in 58 patients. Removal was successful in 98% of patients (57 of 58); 79% of the nodules (53 of 65) were cancers; 20% of these were primary lung cancers of which 9 were pure ground-glass opacities. Mean size of the nodules was 9.9 ± 4.6 mm (range, 3 to 24 mm). Mean depth from visceral pleura surface was 18.7 ± 12 mm (range, 2 to 35 mm). Mean procedure time was 58.7 ± 20.1 minutes (range, 30 to 120), and mean length of stay was 2 days (range, 1 to 6). Complications occurred in 3 patients and included fiducial embolization, fiducial migration, and parenchymal hematoma. Conclusions. Fiducial localization facilitates identification and removal of small pulmonary nodules and alleviates the need for direct nodule palpation. As shown by our series, thoracoscopic wedge resection with fiducial localization is an accurate and efficient technique. This method provides a standardized means by which to resect small and deep pulmonary nodules or ground-glass opacities. [ABSTRACT FROM AUTHOR]

Background: In 2013, the Centers for Medicare and Medicaid Services began its Bundled Payments for Care Improvement Initiative. If payments are to be bundled, surgeons must be able to predict which patients are at risk for more costly care. We aim to identify factors driving variability in hospital costs after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Methods: Our institutional Society of Thoracic Surgeons data were queried for patients undergoing VATS lobectomy for lung cancer during fiscal years 2010 to 2011. Clinical outcomes data were linked with hospital financial data to determine operative and postoperative costs. Linear regression models were created to identify the impact of preoperative risk factors and perioperative outcomes on cost. Results: One hundred forty-nine VATS lobectomies for lung cancer were reviewed. The majority of patients had clinical stage IA lung cancer (67.8%). Median length of stay was 4 days, with 30-day mortality and morbidity rates of 0.7% and 37.6%, respectively. Mean operative and postoperative costs per case were $8,492.31 (± $2,238.76) and $10,145.50 (± $7,004.71), respectively, resulting in an average overall hospital cost of $18,637.81 (± $8,244.12) per patient. Patients with chronic obstructive pulmonary disease and coronary artery disease, as well as postoperative urinary tract infections and blood transfusions, were associated with statistically significant variability in cost. Conclusions: Variability in cost associated with VATS lobectomy is driven by assorted patient and clinical variables. Awareness of such factors can help surgeons implement quality improvement initiatives and focus resource utilization. Understanding risk-adjusted clinical-financial data is critical to designing payment arrangements that include financial and performance accountability, and thus ultimately increasing the value of health care. [Copyright &y& Elsevier]

Background: This study evaluated the feasibility of performing thoracoscopy without lung isolation employing single lumen endotracheal tube (SLET) intubation and carbon dioxide insufflation. Methods: Eighty-two patients underwent a variety of thoracoscopic procedures without lung isolation using SLET intubation and carbon dioxide (CO2) insufflation between January and December 2012. Sixty-five of these patients underwent wedge resections and were isolated for analysis. Operations were accomplished using percutaneously placed laparoscopic trocars and insufflation up to 15 mm Hg. Operative times, length of stay, and vital signs were compared with 52 patients who underwent thoracoscopic wedge resections with double lumen endotracheal tube (DLET) intubation. Results: A retrospective analysis was performed on 65 patients (30 females, mean age 58) who underwent thoracoscopic wedge resections with SLET intubation compared with 52 patients undergoing the same procedure with DLET intubation. Operating room time (111 ± 4.74 minutes), time to incision (49 ± 1.91 minutes), and operative time (48 ± 2.89 minutes) were significantly decreased in the SLET group (p < 0.05). Intraoperative hemodynamic parameters showed no significant aberrations. Two postoperative complications (3.1%) were identified in the SLET group. Length of stay was similar (3 ± 0.49 days versus 3 ± 0.23 days). Conclusions: Single lumen endotracheal tube intubation is a feasible and safe airway management alternative for thoracoscopic procedures. This method resulted in shorter operative times, no aberrant hemodynamic shifts, low complication rates, and similar hospital stays as compared with traditional DLET intubation. [Copyright &y& Elsevier]

Background. Residual disease at the bronchial margin after resection of non-small cell lung cancer (NSCLC) adversely affects survival. To ensure an R0 resection, thoracic surgeons commonly use intraoperative frozen section analysis of the bronchial margin. We hypothesize that frozen section of the bronchial margin is rarely positive and seldom changes intraoperative management. Methods. Our institutional Society of Thoracic Surgery database was queried for all patients undergoing planned lobectomy for NSCLC from 2009 to 2011. Clinical variables, intraoperative data, and postoperative outcomes were reviewed. Specifically, intraoperative frozen section and final pathology results of all bronchial margins were examined. The frequency that frozen section results affected intraoperative decision making was evaluated. Results. A total of 287 lobectomies for NSCLC were performed. Frozen section of the bronchial margin was performed in 270 patients (94.1%). There were 6 (2.2%) true-positive bronchial margins and 1 (0.4%) false-negative margin. In no cases did a positive frozen section lead to a change in operative management; reasons included unable to tolerate further resection (n = 5) and advanced-stage disease (n = 1). Positive margins were more frequent with open techniques (7%) than in video-assisted thoracoscopic operations (0.05%; p < 0.01). Tumors with positive margins were closer to the bronchial margin (1.0 vs 2.5 cm; p = 0.04). Frozen section was not used in 17 patients (5.9%), and none had positive margins on final pathology. Conclusions. Frozen section analysis of the bronchial margin rarely yields a positive result and infrequently changes intraoperative management in patients undergoing NSCLC resection. These data support selective use of intraoperative frozen section of bronchial margins during lobectomy for NSCLC. [ABSTRACT FROM AUTHOR]

Background: Skeletal chest wall reconstruction can be a challenge, depending on the indication, location, and health of the patient; various materials are available. Recently, biomaterials that are remodelable (bovine pericardium patch; Veritas, Synovis Life Technologies Inc, St Paul, MN) or absorbable (polylactic acid [PLA] bar; BioBridge, Acute Innovations, Hillsboro, OR) have been introduced for reconstruction procedures. Methods: We performed a retrospective review of all patients who underwent chest wall stabilization or reconstruction between July 1, 2009, and March 31, 2011. Results: Biomaterials were used in 25 of 112 patients (22%) who underwent chest wall stabilization or reconstruction, and they form the basis of this review. Indication for reconstruction was malignant disease in 17 patients (68%). Overall, 10 (40%) resection sites were infected preoperatively. Reconstruction was performed with a combination of bovine pericardium and PLA bars in 11 patients (44%), bovine pericardium alone in 10, and PLA bars alone in 4; muscle flaps were interposed in 7 patients (28%). There were no operative deaths. Complications occurred in 6 patients (24%). Median follow-up was 12 months (range, 6 to 27 months). Three patients required removal of their biomaterials. Two bovine pericardial patches were removed prophylactically at the time of debridement of a partially necrotic muscle flap, and 1 PLA bar was removed because of an inflammatory reaction. None of the patients with an infected resection site required removal of their biomaterial. Conclusions: Chest wall reconstruction with biomaterials is a valuable option in the management of patients with chest wall abnormalities. Early results are promising. Biomaterials may be the preferred method of reconstruction for infected chest wall sites. [ABSTRACT FROM AUTHOR]

Background: Currently, predicted postoperative (PPO) lung function (forced expiratory volume in 1 second [PPO-FEV1] and diffusion capacity of the lung for carbon monoxide [PPO-Dlco]) estimated from spirometry and regional perfusion is used to select patients for lung resection. Vibration response imaging (VRI) analyzes lung sounds and quantifies regional acoustic energy. Single-center studies suggest that this noninvasive, radiation-free method of quantifying lung function is comparable to the reference standard. Methods: A prospective, multiinstitutional United States study comparing VRI with perfusion in patient assessment for lung resection enrolled 163 patients, with 135 currently available for analysis. PPO values were calculated by subtracting the fraction of segments to be resected in a lung (113 lobectomies, 20 pneumonectomies) multiplied by the percentage of acoustic energy (VRI) or perfusion of that lung. We compared the two methods with each other, with actual postoperative pulmonary function tests, and the rate of complications as predicted by PPO values above or below 40%. Results: Good agreement was found between calculated estimations of postoperative lung function using VRI and perfusion measurements (PPO-FEV1%: r = 0.95; −8% to 11.5%; PPO-Dlco: r = 0.97; −6.6% to 9.5%), although larger discrepancies were noted between the actual VRI and perfusion measurements (−17 to 24). The VRI and perfusion methods provided excellent agreement in categorization of patients into low or elevated risk based on PPO values of above or below 40% (95% for PPO-FEV1%; 94% for PPO-Dlco) and similar correlations with actual postoperative values (r = 0.74 and r = 0.67 for FEV1; r = 0.72 and r = 0.67 for Dlco). Conclusions: VRI may offer a simple, noninvasive, and radiation-free alternative to lung scintigraphy for predicting postoperative lung function in patients with lung malignancies. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the effect of laterality on survival in patients who underwent pneumonectomy for lung cancer. Methods: We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent pneumonectomy for lung cancer from 1988 through 2006. Predictors of survival were determined by univariate and multivariable analysis. Results: A total of 9746 patients had pneumonectomies. Left pneumonectomies (56%) were more common than right; 67% of patients were men with mean age of 63 years (range, 12 to 92 years). Tumor pathology was squamous cell in 49% and adenocarcinoma in 34%. Stage distribution was stage I, 28%; stage II, 28%; stage IIIA, 19%; stage IIIB, 18%; and stage IV, 6%. Overall survival was 67% and 40%, respectively, at 1 and 3 years; with 63% and 39% for right vs 70% and 41% for left (p <0.001). Mortality at 1 and 3 months was 8% and 16% for right pneumonectomies and 4% and 9% for left (p <0.001). Multivariate predictors of worse survival were right pneumonectomy, age, stage, male sex, tumor size, grade, prior malignancy, not married, number of positive lymph nodes, and fewer lymph nodes evaluated (all p <0.05). The adjusted hazard ratio for right pneumonectomy was 1.12 (95% confidence interval, 1.07 to 1.18; p <0.00001). For 3-month survival, right pneumonectomy had an adjusted odds ratio of 2.01 (95% confidence interval, 1.77 to 2.29; p <0.001). Neoadjuvant radiotherapy did not affect 3-month survival (adjusted odds ratio, 0.88; 95% confidence interval, 0.1 to 7.03, p = 0.9). Conclusions: A right pneumonectomy is associated with approximately twice the perioperative mortality as a left pneumonectomy. However, neoadjuvant radiotherapy does not appear to add incremental risk, and long-term survival is not affected by laterality. [ABSTRACT FROM AUTHOR]

Background: Cervical tracheal stenosis can be a difficult condition to manage. Depending on the etiology, location, and extent of the stenosis, tracheal or cricotracheal resection may be required. Intraoperative decisions may predict outcome. Methods: We performed a retrospective chart review of all patients undergoing cervical tracheal or cricotracheal resection from April 2000 through March 2008. Results: One hundred and five patients underwent 108 tracheal or cricotracheal resections. Median age was 65 years (range, 15 to 78); 68% were women. Indication for operation included postintubation tracheal stenosis (38), idiopathic (31), tracheostomy stenosis (19), invasive thyroid cancer (9), and other (8). Median length of trachea resected was 2.7 cm (range, 1.5 to 6.0 cm); 48 patients (46%) underwent extended cricotracheal resections. Twenty-six patients (25%) had an intraoperative chin stitch placed. Hospital stay was a median of 4 days (range, 2 to 33). Operative mortality was (1%); 1 patient died of myocardial infarction on postoperative day 3. Four patients (4%) had hoarseness or vocal cord immobility. Median follow-up was 36 months (range, 1 to 79). Eighteen patients (17%) required dilation postoperatively. Seven patients (7%) required tracheostomy; 2 (2%) are tracheostomy dependent. Three patients (3%) underwent a re-resection for recurrent stenosis. Multivariate analysis of indication for resection, type of resection, length of resection, anastomotic technique, and use of chin stitch did not predict the need for postoperative dilation, tracheostomy, or reoperation. Conclusions: Cervical tracheal resection can be performed safely with low morbidity and mortality. Only 5% of patients required a long-term tracheostomy or re-resection for recurrent tracheal stenosis. Specific intraoperative decisions did not predict long-term success. [Copyright &y& Elsevier]

Background: Single-lung transplantation (SLT) and bilateral lung transplantation (BLT) are both good options for patients with end-stage lung disease secondary to idiopathic pulmonary fibrosis. It is, however, unclear whether BLT offers any survival advantage over SLT. The purpose of our study was to evaluate a large group of patients to determine if either SLT or BLT officered a long-term survival advantage for patients with IPF. Methods: This was an Institutional Review Board-approved retrospective analysis of the United Network of Organ Sharing database from 1987 to 2008. Survival was determined using Kaplan-Meir estimates and the effect of laterality was determined by Cox proportional hazards and propensity analyses. Results: Lung transplantation for idiopathic pulmonary fibrosis was performed in 3,860 patients (2,431 SLTs and 1429 BLTs). Multivariate and propensity analysis failed to show any survival advantage for BLT (hazard ratio = 0.90, 95% confidence interval = 0.78 to 1.0, p = 0.11). One-year conditional survival favored BLT (hazard ratio 0.73, 95% confidence interval 0.60 to 0.87, p = 0.00064). Risk factors for early death included recipient age over 57 and donor age over 36 years. Conclusions: Bilateral lung transplantation should be considered for younger patients with idiopathic pulmonary fibrosis and results may be optimized when younger donors are used. [Copyright &y& Elsevier]

Background: Historically, esophageal perforation has been associated with significant mortality. Improvements in diagnosis, critical care, and surgical and endoscopic techniques may lead to lower mortality rates in the modern era. We reviewed our experience with the management of esophageal perforation to determine whether outcomes have improved. Methods: We retrospectively reviewed all cases of esophageal perforation from 1997 through 2008 at our institution. Univariate and propensity-matching analysis were performed. Results: We reviewed the charts of 147 patients, and 97 met eligibility criteria. There were 45 women, (46.4%); mean age was 60.7 ± 15.6 years. Etiologies included iatrogenic in 50 (51.6%), spontaneous in 23 (23.7%), and idiopathic in 22 (22.7%). Treatment within 24 hours of presentation occurred in 55.2% of patients; 22.7% of patients were septic on presentation. Treatment included surgery in 72 patients (74.2%) and nonoperative management in 25 (25.8%). Forty-one patients (42.3%) underwent primary repair, 5 (6.9%) underwent esophageal resection, 4 (5.6%) underwent exclusion, and 22 (22.7%) underwent drainage or stent placement. Thirty-day mortality rate for the entire cohort was only 8.3% (8 patients). The mortality rate for the primary repair patients was 7.7%, and none of the resection patients died. There was similar in-hospital mortality rate between operative and nonoperative treatment groups (p = 0.96). Propensity-matching analysis showed equal morbidity (p = 0.74) and 30-day mortality (p = 0.35) between operative and nonoperative treatment groups. Conclusions: Our study represents a large series of patients treated for esophageal perforation. The results demonstrate that the overall mortality from esophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Nonoperative management, in appropriate patients, can also lead to good success rates and low mortality. [Copyright &y& Elsevier]

Background: Anatomic sublobar resection is currently being assessed as an alternative to lobectomy for primary lung cancers less than 2 cm in size. Open segmentectomy is a proven oncologic procedure for patients with reduced cardiopulmonary reserve and significant comorbidities. With the increased use of thoracoscopy, a video-assisted thoracoscopic surgery (VATS) segmentectomy may be as safe and effective as an open segmentectomy. Methods: We performed a retrospective review of patients who underwent a segmentectomy between May 2002 and March 2009 at Emory University Hospital. Results: Forty-one patients underwent pulmonary segmentectomy; 26 through thoracotomy (open) and 15 by a thoracoscopic (VATS) approach. Both groups were well matched for age, gender, and preoperative risk factors. Segmentectomy was performed for primary lung cancer in 25 (61%) patients. There was no difference in tumor size, number of lymph node stations sampled, or number of lymph nodes removed based upon approach. The remaining indications for surgery were metastatic disease in 12 patients and benign disease in 4 patients. All patients underwent R0 resections. There was no significant difference in operative time, but patients undergoing a VATS segmentectomy had significantly reduced chest tube durations and hospital stays. Major complications occurred in 19% of patients in the open group and none in the VATS group. There were two operative deaths (4.8%), both in the open group. Conclusions: Video-assisted thoracoscopic surgery segmentectomy is a safe procedure which has fewer complications and a reduced hospital stay when compared with an open segmentectomy. This approach may be the ideal oncologic procedure for patients with small lung cancers (<2 cm) and (or) limited cardiopulmonary reserve and significant comorbidities. [Copyright &y& Elsevier]

Background: Pectus repair in adults can be challenging. Standard repair has been the modified Ravitch procedure. More recently the minimally invasive Nuss procedure, used exclusively in children, has been introduced for correction of pectus deformities in adults. There is a paucity of data on which procedure is most appropriate for adults and even less information on the most appropriate operation for pectus recurrence in adults. The purpose of this study is to determine if any specific patient characteristic exists that places patients at an increased risk for recurrence and describe our management of recurrent pectus defects in adults. Methods: We retrospectively reviewed the records of all patients (>16 years of age) who underwent primary or recurrent repair of pectus deformities from April 1999 through December 2006. Results: Forty-eight patients, 37 (77%) men and 11 women, underwent pectus repair with a median age of 28 years (range, 16 to 54 years). Indication for initial repair was pectus excavatum in 39 (81%) and pectus carinatum in 9. The primary procedure was a modified Ravitch repair in 40 patients and a Nuss procedure in 8. Thirteen patients (27%) underwent reoperation for recurrence; 8 (62%) patients had undergone a previous Nuss procedure and 5 had a modified Ravitch repair. All reoperative patients had a primary pectus index (PI) greater than 4.0, while 8 (62%) also had an asymmetrical defect. All failed Nuss procedure patients underwent a modified Ravitch repair for correction, while the recurrent open repair patients required complex reconstructions. Results were good or excellent in greater than 90% of patients undergoing a reoperative procedure. Conclusions: Adults with severe pectus deformities (PI > 4.0) and asymmetric defects are at a greater risk of recurrence after a Nuss procedure. These patients may better be served with a modified Ravitch repair initially. Reoperation for failed pectus repair in adults can be performed safely with outstanding results. [Copyright &y& Elsevier]

Background: Esophagomyotomy is the mainstay of treatment for achalasia with proven long-term success. However, in patients with a significantly dilated esophagus, many advocate esophageal resection thus forgoing an esophagomyotomy. The purpose of this study is to determine the esophagomyotomy failure rate in patients with achalasia. Methods: A retrospective review of all patients with achalasia who underwent an esophagomyotomy from 1996 to 2006; 272 patients were divided into three groups based on their preoperative degree of esophageal dilation for comparison. The endpoint for esophagomyotomy failure was persistent symptoms requiring any intervention. Results: The preoperative characteristics were comparable except for the severely dilated esophagus patients who had a longer duration of preoperative symptoms. Group I (mild dilatation) had 162 patients with 7 failures requiring intervention. Group II (moderate dilatation) had 74 patients with 4 failures and group III (severe dilatation) had 36 patients with 5 patients requiring intervention. For the entire cohort, median follow-up was 37 months (range, 8 to 144 months). There was no statistically significant difference among the groups in the number of patients requiring reintervention. The overall esophagectomy rate was only 2%. However, there was a significantly higher (p = 0.02) esophagectomy rate in the severely dilated patients. Conclusions: The degree of esophageal dilatation associated with achalasia does not influence the success of an esophagomyotomy. Of the entire patient population in this study, only 6 patients required an esophagectomy. The majority of patients with the most severely dilated esophagus did not require an esophagectomy. Esophagomyotomy should be the first treatment option for patients with achalasia no matter what the degree of esophageal dilatation. [Copyright &y& Elsevier]

Background: The presence of Barrett''s esophagus (BE) increases the risk of esophageal cancer. Total regression of BE is uncommon with medication or laparoscopic fundoplication, and endoscopic techniques to obliterate BE have varied results. This study evaluated the early results of a balloon-based catheter radiofrequency ablation (RFA) system in patients with medically refractory reflux symptoms and biopsy-proven BE. Methods: The medical records of 27 consecutive patients who underwent RFA for BE from March 2005 through January 2007 were reviewed. Esophagogastroduodenoscopy was performed before ablation to document presence of BE and no cancer and at 8 weeks after the RFA to assess the presence of residual BE. Results: Mean patient age was 53.6 ± 12.5 years; 16 (59%) were men. The average length of the Barrett segment treated was 4.6 ± 4.7 cm. Two patients (7.4%) had low-grade dysplasia. No patient had high-grade dysplasia and cancer. There was no periprocedural morbidity or at follow-up, no postprocedure dysphagia or stricture. In all patients, the BE was completely replaced with normal squamous epithelium. Symptoms regressed in 16 patients (60%) with RFA and proton pump inhibitor therapy. Eleven required an antireflux procedure for persistent symptoms. Conclusions: Short-term results show that RFA for BE is safe and achieves 100% replacement of intestinal metaplasia. RFA of BE combined with fundoplication may be offered to patients with BE and medically refractory reflux symptoms. Long-term endoscopic surveillance is needed to determine if the risk of cancer is reduced with this bimodality therapy. [Copyright &y& Elsevier]

Background: Neoadjuvant chemoradiation followed by esophagectomy is currently the standard of care for locally advanced esophageal cancer. This intense preoperative regimen delays definitive resection and increases perioperative risks. With the improvement of chemotherapy agents, chemotherapy alone may be better suited for patients awaiting esophagectomy because of shorter preoperative treatment time and less associated perioperative complications. No recent study has compared chemoradiation to chemotherapy alone before esophageal resection with respect to operative morbidity and mortality and overall survival. Methods: A retrospective review was performed of all patients (281) who underwent an esophagectomy for cancer at our institution from July 1995 through June 2005; 122 patients (43%) had neoadjuvant treatment and form the basis of this study. Results: Preoperative chemoradiation (CR) was administered in 64 patients and chemotherapy only (CO) in 58 patients. Operative mortality was 6% (4 patients) in the CR group and 0% in the CO group (p = 0.12). Overall postoperative complications rate was 48% in CR patients and 33% in CO patients (p = 0.09). Complete pathologic response occurred in 11 CR patients (17%) and in 2 CO patients (4%; p = 0.02). There was no difference in recurrences between the two groups (p = 0.43). Median survival was 17 months in the CR patients and 21 months in the CO patients (p = 0.14). One-, 3-, and 5-year survivals were 76%, 46%, and 41%, respectively, in the CR patients and 70%, 40%, and 31%, respectively, in the CO patients (p = 0.31). Conclusions: Although neoadjuvant chemoradiation resulted in a significantly better complete pathologic response rate when compared with chemotherapy alone, that did not translate into a long-term survival advantage. Chemotherapy alone may be the preferred neoadjuvant modality to expedite resection, decrease operative mortality and postoperative complications, and improve survival in patients with locally advanced esophageal cancer. [Copyright &y& Elsevier]

Background: Compensatory hyperhidrosis (CH) is the most common side effect after a thoracoscopic sympathectomy. The fear of CH is the most common reason why patients do not undergo a sympathectomy, because it is an irreversible procedure unless removal clips are used. Unfortunately, clip removal for reversal of postsympathectomy CH has not been reliable. To address this issue, we developed a new technique of a temporary thoracoscopic sympathetic block that can hopefully predict if postsympathectomy CH is going to occur after sympathectomy for medical refractory primary hyperhidrosis (PH). Methods: We reviewed all patients who underwent a temporary thoracoscopic sympathetic block and subsequent thoracoscopic sympathectomy for medical refractory PH. All patients were concerned about the development of CH and requested the possibility of a reversible procedure. Results: Twenty-five patients underwent a temporary thoracoscopic sympathetic block; 18 suffered from palmar, axillary, and plantar hyperhidrosis, 4 had axillary and plantar hyperhidrosis; and 3 had palmar and plantar hyperhidrosis. The sympathetic block and subsequent sympathectomy were performed as outpatient bilateral thoracoscopic procedures. Sympathetic blockade was performed at each level of the planned sympathectomy (T2, T3, and accessory nerves) with 2.5 cc 0.25% marcaine with epinephrine per level without complications. All patients had temporary relief of hyperhidrosis ranging from 1 to 10 days with a median of 4 days after the block. Three patients (12%) had temporary CH after the thoracoscopic block, 2 mild and 1 severe. All but 1 (4%), the severe CH patient, elected to proceed with the planned sympathectomy; all sympathectomy patients (100%) were cured of their excessive sweating. The 2 patients who experienced mild CH after the thoracoscopic block also had it after the sympathectomy. All patients were completely satisfied with the final results, even the 2 patients in whom mild CH developed. Conclusions: Temporary thoracoscopic sympathetic block is a reversible and accurate procedure for the determination of postsympathectomy CH. A temporary thoracoscopic sympathetic block followed by sympathectomy may be the best approach for the treatment of medically refractory PH in patients who are concerned about the development of postsympathectomy CH. [Copyright &y& Elsevier]

Background: Sympathectomy for palmar hyperhidrosis has been performed for more than 80 years with excellent long-term results. However, several issues are still unresolved: best surgical approach, which level and the number of levels of the sympathetic chain should be divided and the safety of an outpatient procedure. Methods: We reviewed the records of 205 patients who underwent sympathectomy for hyperhidrosis at our institution from April 2002 through March 2005. Fifty consecutive patients (24%) underwent an outpatient microthoracoscopic sympathectomy of a single level (T2) for palmar hyperhidrosis. Operative reports, medical records, and clinical charts were reviewed to determine the success of a single level sympathectomy, the incidence of postoperative compensatory hyperhidrosis, and the safety of an outpatient sympathectomy procedure. Results: There were 41 women (82%) and 9 men. Median age was 22 years (range, 14 to 62). The surgical technique consisted of single-lumen endotracheal tube general anesthesia, single bilateral access incisions (4 mm), 3-mm, 30-degree thoracoscope, temporary CO 2 insufflation, electrocautery nerve division, and no chest drainage. Median operating time was 22 minutes (range, 14 to 50). Sympathectomy consisted of dividing the sympathetic chain at the T2 level and any accessory nerves present. Anatomically, 19 patients (38%) had accessory nerves, right sided in 11, left sided in 5, and bilateral in 3. Two patients (4%) had a chest tube (10F) placed at the time of sympathectomy because of required lysis of apical pleural adhesions. No patient had postoperative bleeding or a wound infection. All patients were discharged the day of surgery. Median follow-up was 15 months (range, 1 to 36). Compensatory hyperhidrosis developed in 6 patients (12%), in 4 with rest and in 2 during exercise, all within 4 weeks. Successful sympathectomy was achieved in 99% of palmar surfaces without recurrence. A single patient experienced persistent sweating of the left hand. Reoperation was successful by dividing level T3. Conclusions: Single level (T2) microthoracoscopic sympathectomy for palmar hyperhidrosis has a high success rate with a low incidence of compensatory hyperhidrosis. This minimally invasive procedure can be performed safely as an outpatient and should be the preferred treatment for medical refractory palmar hyperhidrosis. [Copyright &y& Elsevier]

Background: Delayed chest closure (DCC) may be used after bilateral lung transplantation when significant bleeding/coagulopathy or severe pulmonary edema exists. Primary chest closure (PCC) in these patients can lead to heart and lung compression causing cardiopulmonary instability. The purpose of this study is to describe factors associated with DCC and evaluate outcomes after DCC. Methods: We performed a retrospective review of all patients undergoing bilateral lung transplantation between September 2003 and March 2005. Statistical significance was determined by two-tailed t test or Fisher’s exact test. Results: Twenty-eight bilateral lung transplantations were performed. Indication for transplant was chronic obstructive pulmonary disease (13), pulmonary fibrosis (5), cystic fibrosis (5), sarcoidosis (3), and pulmonary hypertension (1). Seven patients (25%) required DCC. Mean time to DCC was 5.3 days. Six patients (86%) with DCC required tracheostomy versus 4 patients (20%) with PCC (p = 0.003). Mean days to discharge was 44 in the DCC group and 21 in the PCC group (p = 0.03). Thirty-day survival was 100% in the DCC group and 95% in the PCC group (p = 1.0). There were no wound infections in either group, and 1 patient in the PCC group had sternal nonunion. Delayed chest closure was associated with cardiopulmonary bypass use (p = 0.006), cardiopulmonary bypass time longer than mean cardiopulmonary bypass time (mean, 224 minutes; p = 0.04), PaO2/FiO2 less than mean + 1 SD (value = 4.63, p = 0.0002), evidence of moderate/severe reperfusion injury on chest radiograph (p = 0.0002), and PaO2/FiO2 less than mean plus moderate/severe reperfusion injury on chest radiograph (p = 0.002). Conclusions: Cardiopulmonary bypass use, prolonged cardiopulmonary bypass time, and significant reperfusion injury, as determined by chest radiograph and a low PaO2/FiO2 ratio were all associated with an increased incidence of DCC in our bilateral lung transplantation patients. These patients had no wound infections or sternal complications, and although they had longer hospital stays than PCC patients, DCC did not affect operative survival. Delayed chest closure can be employed safely, when necessary, after bilateral lung transplantation with outcomes similar to patients with PCC. [Copyright &y& Elsevier]

Background: Tracheostomy after median sternotomy is associated with an increased risk of deep sternal wound infection (DSWI). However, associated comorbidities in these patients make the exact risk of tracheostomy difficult to discern. Therefore, we performed a retrospective review to determine the risk of DSWI in our cardiac surgery patients who underwent postoperative tracheostomy. Methods: Our cardiac surgery database was queried from January 1996 to July 2003. Perioperative morbidities were identified for all patients who underwent tracheostomy after cardiac surgery. Statistical analysis was performed using χ2 analysis and Fisher’s exact test. Results: During the study period, 16,277 cardiac procedures were performed through a median sternotomy. Tracheostomy was performed in 291 patients (1.8%). Deep sternal wound infections occurred in 0.8% of all patients and in 3.4% of patients (9 of 268) who underwent tracheostomy. Mean number of days to tracheostomy was 14.2 in the DSWI group and 15.8 in the non-DSWI group (p = 0.45). In patients with a tracheostomy, preoperative renal failure was the only perioperative comorbidity found to be significantly associated with DSWI (p = 0.03). Overall operative mortality was 3.6%. Mortality was 16.5% for patients with DSWI, 22.7% for patients requiring tracheostomy, and 55% for patients with DSWI and tracheostomy. Conclusions: The incidence of DSWI after tracheostomy, in our experience, is not as high as previously reported. Tracheostomy can be performed safely after median sternotomy with a low morbidity and mortality rate. However, if DSWI occurs after tracheostomy, mortality is significant. [Copyright &y& Elsevier]

Ectopic parathyroids can often present a diagnostic and therapeutic conundrum for clinicians. Mediastinal parathyroid adenomas are usually small and located anteriorly within thymic tissue. To our knowledge, this is the first reported case of a large cystic parathyroid adenoma presenting as a 6-cm posterior mediastinal mass. After a successful thoracoscopic resection, parathyroid hormone levels normalized and the patient was discharged home on postoperative day 2. [ABSTRACT FROM AUTHOR]

Background: Different modalities are used to diagnose interstitial lung disease. We compared the effectiveness of minimally invasive surgical biopsy versus high-resolution computed tomography for the diagnosis of interstitial lung disease and report the mortality of the procedure. Methods: We reviewed 194 patients undergoing video-assisted thoracoscopic lung biopsies for the suspicion of interstitial lung disease from January 2003 to February 2012 at Emory University. Demographics and patient characteristics were analyzed in addition to final diagnoses and clinical outcomes. Results: Concordance of radiographic diagnosis with final diagnosis was poor, matching pathologic diagnosis in 15% of cases, and specific diagnoses were included in the radiographic differential in only 34% of cases. A specific diagnosis was made after surgical biopsy in 88% of cases. Overall mortality of surgical biopsy was 6.7% (13/194). Major risk factors for death were preoperative supplemental oxygen, ventilator dependence, and age (p < 0.0001, p < 0.0001, and p = 0.03, respectively). Among patients with ventilator dependence preoperatively, the mortality rate was 100% versus 4.8% in patients not ventilator dependent. All biopsy specimens were concordant 91% of the time, and the first two biopsy specimens were concordant 96% of the time. Conclusions: Surgical biopsy should remain the gold standard for diagnosis of interstitial lung disease. The mortality is low with proper patient selection. More than two surgical biopsy specimens may not be needed because the concordance rates among pathologic specimens are very high. [Copyright &y& Elsevier]

Patients with secondary pulmonary hypertension frequently present for evaluation for lung transplantation. In some of these patients, Eisenmenger’s syndrome has developed from chronic left to right intracardiac shunts. A smaller group of these patients will also have associated pulmonary artery aneurysms. There is a paucity of literature discussing this topic, however, and currents reports have suggested the need to replace the abnormal pulmonary artery. This paper discusses a patient in whom Eisenmenger’s syndrome developed from an atrial septal defect, and resultant pulmonary artery aneurysms and mural thrombi, who underwent successful bilateral lung transplantation with thromboendarterectomy and atrial septal defect closure. [Copyright &y& Elsevier]

Diaphragmatic hernia complicating pregnancy rarely occurs, but it is frequently misdiagnosed. A strangulated diaphragmatic hernia in a pregnant patient presents a true surgical emergency, and delay in operative intervention can result in fetal and maternal mortality in as many as 50% of cases. We describe a case report of a pregnant patient and her fetus surviving after a spontaneous gastric rupture from a strangulated diaphragmatic hernia. [Copyright &y& Elsevier]

Symptomatic pericardial cysts requiring operative management are rare entities. We present a patient with a symptomatic intra-pericardial cystic lesion with intermittent syncope who underwent treatment using a laparoscopic approach, thus minimizing pain and allowing quick recovery. [ABSTRACT FROM AUTHOR]

Plastic bronchitis is a rare and potentially life-threatening disease characterized by the development of obstructive fibrinous tracheobronchial casts and hypoxic respiratory failure. With its poorly understood cause and rare occurrence in the adult population, few treatment strategies have been described in adults with this condition. In this report, we present a case of successful treatment of an adult with plastic bronchitis, using thoracic duct ligation and resulting in full resolution of airway cast development. [ABSTRACT FROM AUTHOR]

We report a patient with significant dysphagia from hypercontractile “jackhammer” esophagus and a midesophageal pulsion diverticulum. This was treated with a thoracoscopic diverticulectomy and a long esophageal myotomy sparing the lower esophageal sphincter (LES). We describe the clinical diagnosis and surgical treatment of this uncommon esophageal motility disorder. To our knowledge, this is the first report in the literature of a midesophageal diverticulum caused by jackhammer esophagus. We propose that in the setting of normal LES function, successful treatment should include diverticulectomy with an LES-sparing myotomy. [ABSTRACT FROM AUTHOR]

We report an Epstein-Barr virus (EBV)–associated pulmonary posttransplant smooth muscle tumor arising in the left lung of a 71-year-old bilateral lung transplant recipient nearly 3 years after transplantation, treated with thoracoscopic wedge resection. Four previous smooth muscle tumors have been reported following lung transplantation. To our knowledge, this is the first reported case of an EBV-positive posttransplant smooth muscle tumor within the transplanted lung. We describe the clinical, pathologic, and histologic diagnosis of this uncommon tumor. [ABSTRACT FROM AUTHOR]

Pulmonary agenesis is a rare congenital disease that is associated with many other congenital anomalies. We present the case of a patient, with right pulmonary agenesis and transmediastinal lung herniation, who presented with a spontaneous pneumothorax. This congenital anomaly and the treatment for this rare presentation is discussed in detail. [ABSTRACT FROM AUTHOR]