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Background: Delayed distal esophageal reconstruction with nonsupercharged jejunum is an option when gastric conduit is not available. This study aimed to describe a single-center experience with distal esophageal reconstruction with retrosternal Roux-en-Y esophagojejunostomy (RYEJ) and compare perioperative outcomes with retrosternal gastric pull-up (GP)., Methods: An Institutional Review Board-exempt retrospective chart review was conducted of patients who underwent esophagostomy closure by the retrosternal route at the University of Minnesota Medical Center (Minneapolis, MN) from January 2009 to July 2019. Patients with colonic conduits were excluded. The study compared patients with RYEJ with a contemporary cohort of patients who underwent GP. The anatomic criteria for RYEJ were the absence of a gastric conduit and an esophageal remnant that reached the sternomanubrial joint. Patient characteristics, anastomotic leak and stricture rate, postoperative complications, hospital length of stay, 30-day readmission, and 90-day mortality were recorded. Statistical analysis was performed using the Fisher exact test and the Wilcoxon rank-sum test with a significance level at P ≤.05., Results: A total of 9 patients underwent RYEJ, and 10 patients had GP. Previous esophageal adenocarcinoma was more common in the RYEJ group (n = 5) compared with the GP group (n = 0) (P = .01). Patient demographics and comorbidities were comparable between the groups. No differences were found in all end points, including operating time, estimated blood loss, anastomotic leak or stricture rate, Clavien-Dindo class III to IV complications, hospital length of stay, or mortality., Conclusions: Retrosternal RYEJ without microvascular augmentation is a safe alternative for esophagostomy closure in patients with adequate esophageal length when the stomach is not available. The nonsupercharged jejunum can safely reach the level of the sternomanubrial joint., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Diaphragmatic hernias after explantation of a left ventricular assist device (LVAD) at the time of heart transplantation are uncommon, but they can cause morbidity. This study presents midterm to long-term results of diaphragmatic hernia repair in these patients., Methods: A retrospective chart review was performed on a prospectively collected database of all patients who underwent sequential LVAD explantation and heart transplantation at the University of Minnesota (Minneapolis, MN) since 1995. All patients who had a diaphragmatic hernia were included in the study. Patients' demographics, perioperative morbidity, and long-term results were recorded., Results: From January 1995 to June 2018, 712 LVADs were placed, and subsequently 293 hearts were transplanted. The incidence of diaphragmatic hernia after heart transplantation was 7.1% (n = 21), with a median time from transplantation to diagnosis of 23 months (interquartile range [IQR], 9 to 39 months). Four patients did not undergo operative repair, and 1 patient was excluded for insufficient data. Sixteen patients underwent diaphragmatic hernia repair (male, 13; female, 3). Thirteen patients underwent laparoscopic repair with mesh, and 3 patients had open repair. Two patients presented with strangulated hernias requiring laparotomy and bowel resection. Median follow-up time was 53 months (IQR, 12 to 141 months) for the entire cohort. One recurrence was noted (6.2%), in a patient with laparoscopic repair., Conclusions: Diaphragmatic hernia repair after sequential LVAD explantation and orthotopic heart transplantation is feasible and appears to be safe. When this hernia is diagnosed, patients should be referred for surgical evaluation., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Diaphragmatic eventration and diaphragmatic paralysis are 2 entities with different etiology and pathology, and are often clinically indistinguishable. When symptomatic, their treatment is the same, with the objective to reduce the dysfunctional cephalad excursion of the diaphragm during inspiration. This can be achieved with diaphragmatic plication through the thorax or the abdomen with either open or minimally invasive techniques. We prefer the laparoscopic approach, due to its easy access to the diaphragm and to avoid pain associated with intercostal incisions and instrument use. Short-term and long-term results are excellent with this technique., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Mediastinoscopy (MED) and endobronchial ultrasonography with transbronchial needle aspiration (EBUS-TBNA) have similar accuracy for mediastinal lymph node sampling (MLNS). The threatened financial and environmental sustainability of our health care system mandate that surgeons consider cost and environmental impact in clinical decision making of similarly effective procedures. We performed a cost and waste comparison of MED versus EBUS-TBNA for MLNS to raise awareness of the financial and environmental implications of our practices., Methods: We conducted a retrospective review of outpatients who underwent MLNS under general anesthesia in the OR with MED or EBUS-TBNA (September 2007 to December 2009). We analyzed direct costs based on hospital charges, calculated expected payment using a decision support model, and profit margins (modeled expected payment-direct costs). Our waste comparison was measured in kilograms of solid waste per case., Results: We performed MLNS in 148 patients (89 EBUS-TBNA, 39 MED, 20 EBUS + MED). Direct costs were lower for MED ($2,356) compared with EBUS-TBNA ($2,503), whereas expected payment was greater (MED, $3,449; EBUS-TBNA, $3,249), resulting in a profit margin that was $347 greater for MED. The amount of solid waste for each MED was 1.8 kg versus 0.5 kg for EBUS-TBNA., Conclusions: MED costs less than EBUS-TBNA in the OR setting but generates 3.6 times the amount of EBUS-TBNA waste. The cost of EBUS-TBNA may improve by performance in the endoscopy suite, and surgical pack revision could reduce the amount of MED solid waste. This comparison sets the stage for sophistication of our clinical decision making, taking into consideration the major threats to our health care system., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Mediastinal staging in patients with non-small cell lung cancer (NSCLC) with endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) requires a high negative predictive value (NPV) (ie, low false negative rate). We provide a conservative calculation of NPV that calls for caution in the interpretation of EBUS results., Methods: We retrospectively analyzed our prospectively gathered database (January 2007 to November 2011) to include NSCLC patients who underwent EBUS-FNA for mediastinal staging. We excluded patients with metastatic NSCLC and other malignancies. We assessed FNAs with rapid on-site evaluation (ROSE). The calculation of NPV is NPV = true negatives/true negatives + false negatives. However, this definition ignores nondiagnostic samples. Nondiagnostic samples should be added to the NPV denominator because decisions based on nondiagnostic samples could be flawed. We conservatively calculated NPV for EBUS-FNA as NPV = true negatives/true negatives + false negatives + nondiagnostic. We defined false negatives as negative FNAs but NSCLC-positive surgical biopsy of the same site. Nondiagnostic FNAs were nonrepresentative of lymphoid tissue. We compared diagnostic performance with the inclusion and exclusion of nondiagnostic procedures., Results: We studied 120 patients with NSCLC who underwent EBUS-FNA; 5 patients had false negative findings and 10 additional patients had nondiagnostic results. The NPV with and without inclusion of nondiagnostic samples was 65.9% and 85.3%, respectively., Conclusions: The inclusion of nondiagnostic specimens into the conservative, worst-case-scenario calculation of NPV for EBUS-FNA in NSCLC lowers the NPV from 85.3% to 65.9%. The true NPV is likely higher than 65.9% as few nondiagnostic specimens are false negatives. Caution is imperative for the safe application of EBUS-FNA in NSCLC staging., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Data comparing survival after lobectomy versus that after segmentectomy for stage I non-small cell lung cancer (NSCLC) are limited to single-institution observational studies and 1 clinical trial. We sought to determine if lobectomy offers a survival advantage over segmentectomy for stage I NSCLC based on population-based data., Methods: Using the Surveillance Epidemiology and End Results (SEER) database (1998 to 2007), we identified patients who underwent either anatomic segmentectomy or lobectomy. Wedge resections were excluded. Analysis was limited to patients with stage I adenocarcinoma or squamous cell carcinoma. After stratifying patients based on tumor size (less than or equal to 2.0 cm, 2.1 to 3.0 cm, and 3.1 to 7.0 cm), we assessed for association between extent of resection and survival using the Kaplan-Meier method. To adjust for potential confounding variables, we used Cox proportional hazards regression models., Results: There were 14,473 patients who met our inclusion criteria. Lobectomy conferred superior unadjusted overall (p < 0.0001) and cancer-specific (p = 0.0053) 5-year survival compared with segmentectomy. Even after adjusting for patient factors, tumor characteristics, and geographic location, we noted that patients who underwent lobectomy had superior overall and cancer-specific survival rates, regardless of tumor size. Squamous cell histologic type, male sex, low lymph node counts, and increasing age, tumor size, and grade were all independent negative prognostic factors., Conclusions: Using a population-based data set, we found that lobectomy confers a significant survival advantage compared with segmentectomy. Our results provide additional evidence supporting the role of lobectomy as the standard of care for resection of stage I NSCLC regardless of tumor size., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Conditional cancer-specific survival rates account for changes in the risk of death from cancer over time. There may be a point during follow-up when patients who undergo lobectomy for stage I non-small cell lung cancer (NSCLC) are as likely to die of cardiovascular disease as of cancer., Methods: Using the Surveillance Epidemiology and End Results Database (1988 through 2005), we identified patients 50 years old and older who underwent lobectomy for stage I NSCLC. We used competing risks methods to calculate conditional survival rates and to ascertain if there is a point in follow-up where the risk of dying of cancer is equivalent to the risk of dying of cardiovascular disease., Results: In all, 22,518 patients met our inclusion criteria. The difference in the 5-year conditional probability of dying of cancer and the 5-year conditional probability of dying of cardiovascular disease decreased with time; in the whole cohort, these probabilities were equivalent if patients survived to 7 years after lobectomy (p = 0.11). With increasing age, the probability of dying of cancer and the probability of dying of cardiovascular disease became equivalent at earlier time points. Furthermore, the 5-year probability of dying of cardiovascular disease was significantly greater than the 5-year probability of dying of cancer for patients aged 70 to 79 years who survived to 7 years and for patients aged 80 years and older who survived to 5 years after lobectomy., Conclusions: For patients undergoing lobectomy for stage I NSCLC, cardiovascular-specific mortality becomes increasingly important over the course of follow-up, especially among elderly patients., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component. The etiology of giant HH is not entirely clear, and two potential mechanisms exist: (1) gastroesophageal reflux disease (GERD) leads to esophageal scarring and shortening with resulting traction on the gastroesophageal junction and gastric herniation; and (2) chronic positive pressure on the diaphragmatic hiatus combined with a propensity to herniation leads to gastric displacement into the chest, resulting in GERD. The short esophagus and GERD are key concepts to understanding the pathophysiology of giant HH, and these concepts are critical to address this problem appropriately. A successful repair of giant HH requires adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), recognition and correction of a short esophagus, and a well-performed antireflux procedure. Recurrence rates for open giant HH repairs in expert hands range between 2% and 12%; large series have demonstrated that meticulous laparoscopic surgical technique can emulate the results of open giant HH repair., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A thoracic surgeon facile in endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) can accurately sample mediastinal lymph nodes (MLNs) for histologic assessment of mediastinal adenopathy and for thoracic malignancy staging. Although mediastinoscopy is the gold standard for histologic MLN assessment, EBUS-FNA and EUS-FNA have emerged as useful, less-invasive sampling techniques that offer access to a wider range of MLN stations than mediastinoscopy and can be used to biopsy suspicious lesions within (ie, peribronchial masses) and outside the mediastinum (ie, left adrenal gland masses, liver lesions, and enlarged celiac lymph nodes). The negative predictive value of EBUS-TBNA and EUS-FNA in patients with malignancy is somewhat lower than the negative predictive value of mediastinoscopy. Therefore, we recommend that nonmalignant EBUS or EUS cytologic findings should be confirmed with a surgical MLN biopsy (ie, mediastinoscopy or thoracoscopy) if the pretest probability of malignancy is high., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The current review focuses on a clinical comparison of lobectomy by means of video-assisted thoracoscopic surgery (VATS) and open lobectomy. The best available evidence strongly suggests that VATS lobectomy is less morbid than open lobectomy, and that VATS lobectomy is less immunosuppressive and elicits a milder inflammatory response than open lobectomy. Midterm to long-term oncologic results of patients with early-stage non-small cell lung cancer appear to be equivalent for VATS and open lobectomy. Because a large, prospective, randomized, multiinstitutional trial of open versus VATS lobectomy will likely never take place, we are dependent on the summarized information to draw practical conclusions., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Although etiology and pathology of symptomatic diaphragm paralysis and eventration are distinct, their treatments are the same: to reduce dysfunctional caudal excursion of the diaphragm during inspiration by plication. Minimally invasive diaphragm plication techniques have emerged as equally effective and less morbid alternatives to open plication. This review focuses on the etiology, pathophysiology, diagnosis, and treatment of diaphragmatic eventration or paralysis in adults., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Because of its consistent anatomy, long vascular pedicle, malleability, low complication rate, and low donor site morbidity, we prefer serratus anterior transposition muscle flaps for prophylactic coverage of irradiated bronchi and treatment of bronchopleural fistulas. Our surgical technique is described, and our outcomes are discussed. Serratus anterior transposition muscle flaps can be performed with minimal morbidity and minimal impairment of upper extremity function.

Symptomatic diaphragmatic eventration is an uncommon condition and is sometimes impossible to distinguish clinically from paralysis. Patients who are asymptomatic require no treatment; patients who are symptomatic benefit significantly from diaphragm plication. The choice of plication approach is dependent upon the expertise of the surgeon.

Background: This study was conducted to establish an objective approach to evaluate symptoms and sweat production in patients with primary palmoplantar hyperhidrosis (PPH) and assess their response to bilateral thoracoscopic sympathectomy (BTS)., Methods: We conducted two institutional review board-approved studies. We performed a one-time evaluation of healthy volunteers (controls) with three questionnaires (Hyperhidrosis Disease Severity Scale, Dermatology Life Quality Index, and Short Form-36) and measurement of transepidermal water loss (TEWL; g/m(2)/h). We evaluated PPH patients with these same tools before and 1 month after BTS and compared them with controls., Results: We evaluated 35 controls (mean age, 23.0 +/- 3.3 years) and 45 PPH patients (mean age, 26.5 +/- 12.3 years); 18 PPH patients underwent BTS and the 1-month postoperative evaluation. Hyperhidrosis Disease Severity Scale and Dermatology Life Quality Index scores were higher in PPH patients than in controls (p < 0.0001), but normalized after BTS. Short Form-36 scale scores were lower in PPH patients than in controls (p < 0.05), but improved significantly after BTS. Compared with controls, preoperative TEWL values were significantly higher in PPH patients (palmar: 142.7 +/- 43.6 PPH vs 115.8 +/- 48.7 controls, p = 0.011; plantar: 87.5 +/- 28.8 PPH vs 57.7 +/- 24.7 controls, p < 0.0001). After BTS, palmar TEWL values were significantly lower (49.1 +/- 29.8, p < 0.0001). Plantar TEWL did not change significantly (77.6 +/- 46.6, p = 0.52)., Conclusions: PPH patients should be objectively evaluated with standardized quality of life measures and TEWL measurements before and after treatment. We believe that this objective practical approach provides a benchmark for clinical practice and research.

Background: Video-assisted thoracoscopic surgery (VATS) for patients with early-stage non-small-cell lung cancer is associated with lower stress responses and potentially improved outcomes, as compared with thoracotomy. The goal of our study was to examine the cellular components of the postoperative immune response. Specifically, we assessed the cytotoxic capacity of peripheral blood mononuclear cells (PBMCs) of patients undergoing lobectomy for non-small-cell lung cancer by either VATS or thoracotomy., Methods: We performed a prospective cohort study of lobectomy patients undergoing either VATS or thoracotomy. We isolated PBMCs from perioperative blood samples, and performed cytokine analysis on plasma fractions. Using flow cytometry, we analyzed PBMC phenotype (CD3, CD16/56, CD4, CD8) and T-cell activation markers (CD25, CD69, HLA-DR). Using a chromium release assay, we quantified cellular cytotoxicity. To assess gene expression differences, we used Affymetrix messenger ribonucleic acid microarray and polymerase chain reaction analysis., Results: A total of 13 patients enrolled in our study: 6, VATS; 7, thoracotomy. On postoperative day 1, interleukin-6 and matrix metalloproteinase-9 were significantly different between the two groups. On day 2, cellular cytotoxicity (0.34) was significantly greater (p < 0.05) after VATS, as compared with thoracotomy (0.18). In both groups, cytotoxicity returned to baseline and was equivalent at first follow-up (VATS, 29.4 days versus thoracotomy, 29.3 days; p > 0.05). We noted minimal yet significant differences in PBMC phenotype, but no differences in T-cell activation makers. A 9-gene polymerase chain reaction-validated subset clustered the two groups with complete concordance., Conclusions: Video-assisted thoracoscopic surgery lobectomy for non-small-cell lung cancer is associated with less impairment of cellular cytotoxicity, as compared with thoracotomy. We found that this difference was not accounted for by PBMC phenotypic changes. Instead, PBMC gene expression changes likely represent the molecular basis of this differential immune response.

Background: The gold standard for mediastinal lymph node evaluation is mediastinoscopy, which is invasive and allows access to only a limited number of mediastinal lymph node (MLN) stations (1, 2, 3, 4, and 7). Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) is emerging as a useful, less invasive technique that offers access to a wider range of MLN stations (2, 3, 4, 7, 10, and 11). We report our initial experience with this procedure., Methods: Using our prospectively maintained database, we performed a single-institution retrospective chart review. Our study group consisted of all patients at the University of Minnesota who underwent EBUS-FNA for evaluation of mediastinal lymphadenopathy or for thoracic malignancy staging from September 1, 2006, through December 15, 2007. To assess our learning curve, we plotted the cumulative sensitivity (%) and accuracy (%) of our EBUS-FNA results as a function of the number of procedures we performed., Results: During the study period, 100 patients underwent EBUS, 92 with FNA. Of these, 56 patients (34 women, 22 men; mean age, 60.4 +/- 13.7 years) met our inclusion criteria. We found no complications. After our first 10 procedures, the sensitivity of our EBUS-FNA results was 96.2%; accuracy was 97.8% (rates comparable with other large series in the literature)., Conclusions: We conclude that the learning curve for EBUS-FNA for thoracic surgeons is about 10 procedures.

Background: Isolated rib lesions detected on bone scanning can pose a diagnostic challenge, particularly in patients with a known primary cancer. The purpose of our study was to assess the diagnostic value of radionuclide-guided rib biopsy with an intraoperative gamma probe., Methods: We conducted a retrospective chart review of 10 patients who underwent an intraoperative gamma probe-guided rib biopsy. Rib defects were identified by radionuclide bone scan. Patients received an intravenous dose of technetium 99m methylene diphosphonate within 6 hours before surgery. The approximate location of the rib defect was scanned with a hand-held gamma probe intraoperatively; an excisional rib biopsy was performed in the area with the highest tracer activity., Results: Median age was 54 years (range, 40 to 83) and median body mass index was 32.5 (range, 23 to 52). Seven patients had a known primary extraosseous cancer and 3 patients had no history of cancer. Seven patients had pain at the time of initial evaluation. The median operative time was 45 minutes, median operative blood loss was 25 mL, and median length of stay was 1 day. Complications occurred in 2 patients: a pneumothorax that did not require treatment and a delayed hemothorax that required tube thoracostomy. Rib biopsy was accurate in all 10 patients; metastatic disease was found in 5 of 7 cancer patients. Pain improved or resolved in 4 patients., Conclusions: The evaluation of isolated rib lesions using radionuclide-guided rib biopsy with an intraoperative hand-held gamma probe is accurate and potentially therapeutic. Thoracic surgeons and oncologists should be aware of this approach.

Background: Lobectomy for patients with clinical stage I non-small cell lung cancer (NSCLC) can be performed by thoracotomy or by video-assisted thoracoscopic surgery (VATS). We compared the operative characteristics and postoperative course for patients with clinical stage I NSCLC who underwent lobectomy by VATS or thoracotomy., Methods: We retrospectively reviewed the charts of all patients undergoing lobectomy for clinical stage I NSCLC from January 1, 1998, through June 30, 2005., Results: We performed 147 lobectomies (88 thoracotomy, 59 VATS) in 147 patients with clinical stage I NSCLC. Patient demographics were similar between groups; however, VATS patients had more hypertension (p = 0.0114), chronic renal insufficiency (p = 0.0479), and previous malignancies (p = 0.0086). The two groups did not differ in pathologic stage, tumor size, histologic results, or number of positive nodes. More total nodes were identified in thoracotomy patients (p = 0.0001), and they had a shorter intensive care unit stay (p = 0.0224). VATS patients had significantly less postoperative pneumonia (p = 0.0023). VATS patients trended toward fewer chest tube days and a shorter hospital length of stay. The two groups did not differ in operative time, blood loss, atrial fibrillation, or number of ventilator days. Median survival between the cohorts was similar (>7.9 years thoracotomy versus >4.6 years VATS, log-rank p = 0.6939)., Conclusions: Patients undergoing VATS lobectomy for clinical stage I NSCLC, despite having more comorbidities, had fewer postoperative complications. The approaches are equivalent in operative time, blood loss, length of stay, and survival rate. Compared with thoracotomy, VATS lobectomy for patients with clinical stage I NSCLC appears to be a less morbid operation.

Background: Treatment of nonseminomatous germ cell tumors frequently requires bleomycin-combination chemotherapy followed by resection of residual disease. Bleomycin administration however raises concerns with respect to postoperative respiratory complications, particularly for patients undergoing large pulmonary resections. We undertook an institutional review to determine the outcome of large pulmonary resections after bleomycin-combination chemotherapy., Methods: Between 1981 and 2001, 530 patients presented to our institution for resection of residual intrathoracic disease for either metastatic testicular or primary mediastinal nonseminomatous germ cell tumors. We subsequently reviewed 32 of these patients who required pneumonectomy (n = 19; RIGHT = 9, LEFT = 10) or bilobectomy (n = 13) after bleomycin-combination chemotherapy., Results: There were four operative deaths (13%). All postoperative deaths occurred in patients undergoing right-sided resections (pneumonectomy, n = 2; bilobectomy, n = 2) as a consequence of pulmonary complications. Operative survivors had a pulmonary morbidity of 18%. Fourteen of 20 long-term survivors were found to have a satisfactory performance status at follow-up., Conclusions: Otherwise young and healthy male nonseminomatous germ cell tumors patients requiring large pulmonary resections after bleomycin-combination chemotherapy appear to be at higher than anticipated risk for pulmonary-related morbidity and mortality. However long-term survivors report an acceptable functional status.