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The Nuss repair involves implants designed for removal after 2-3 years. Although rare, significant complications can occur with bar removal and may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety.A retrospective study was performed including all patients post pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona from 2013-2022.In total, 1,555 bars were removed (683 patients; 71% men; median age 34 (range 15-71)). Of removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track, with one patient requiring subsequent hematoma evacuation/transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Removal in one patient with significantly displaced bars required sternotomy and cardiopulmonary bypass due to aortic injury. Risk factors identified for bleeding included sternal erosion (p.001), bar migration (p.001), higher number of bars (p=.037), and revision of a prior pectus repair (p=0.001). Bar migration was additionally associated with major complications (p.001). Older age, although a risk for overall complications (p=0.001), was not for bleeding.Bar removal can be safely performed in most patients, however, significant complications including bleeding may occur. Identifying potential risk factors and being prepared for rescue maneuvers is critical to prevent catastrophic outcomes.

Pectus excavatum is a common chest wall deformity with inward deviation of sternum and accompanying ribs. The depression can cause symptomatic cardiac compression, although the cardiopulmonary impact remains controversial. We present 2 cases of cardiac transplantation followed by modified minimally invasive pectus excavatum repair due to the hemodynamic consequences of the pectus deformity.

Purpose: There are very little data available comparing outcomes of intensity-modulated proton therapy (IMPT) to intensity-modulated radiation therapy (IMRT) in patients with locally advanced NSCLC (LA-NSCLC). Methods: Seventy-nine consecutively treated patients with LA-NSCLC underwent definitive IMPT (n = 33 [42%]) or IMRT (n = 46 [58%]) from 2016 to 2018 at our institution. Survival rates were calculated using the Kaplan-Meier method and compared with the log-rank test. Acute and subacute toxicities were graded based on Common Terminology Criteria for Adverse Events, version 4.03. Results: Median follow-up was 10.5 months (range, 1-27) for all surviving patients. Most were stage III (80%), received median radiation therapy (RT) dose of 60 Gy (range, 45-72), and had concurrent chemotherapy (65%). At baseline, the IMPT cohort was older (76 vs 69 years, P

Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.

Background Minimally invasive repair of pectus excavatum (MIRPE) has been extended to repair of defects in adults, with reported higher complication rates and outcome failures. The optimal revision for a prior failed MIRPE in an adult has not been identified. We review our experience for this adult population. Methods A retrospective review was performed of 129 patients (age ≥18 years) who underwent revision after a failed pectus excavatum (PE) repair from December 2010 through December 2016. Results In total, 47 of the 129 (36%) revision patients had a prior failed MIRPE, with 98% presenting for revision because of inadequate correction after their initial repair. The median age was 28 years (range, 18 to 54 years), and 77% were men. Thirty-one (66%) patients had indwelling pectus support bars at the revision procedure. Mean time from initial MIRPE to the revision procedure was 3.34 ± 2.9 years. A modified MIRPE was successful in 39 (83%) patients. Hybrid repair with the addition of osteotomy cuts and/or titanium plating was required in 8 patients for an adequate revision. Multiple (2 bars, 62%; 3 bars, 38%), shorter (median, 13.5 inches versus 15.0 inches) bars were used for the revision versus earlier repair. Substantial lysis of intrathoracic adhesions was required in 40 (85%) patients, with a median operative time for revision MIRPE of 169 ± 66 minutes; median operative time for hybrid procedures, 314 ± 74 minutes. Conclusions A modified MIRPE can be successfully used in most adults to revise a failed prior MIRPE.

Pectus excavatum (PE) involves the inward deformity of the sternum and accompanying cartilage attachments. Compression of the right heart and lungs can cause cardiopulmonary disability. Surgical correction is recommended for severe, symptomatic cases. Pectus excavatum can be corrected with a minimally invasive technique that involves placing temporary intrathoracic support bars under the sternum. These bars are then removed after 2-3 years. The minimally invasive Nuss procedure is the standard of care for PE repair in children and adolescents. Minimally invasive repair in more difficult patient repairs, including older teenagers and adults, has required modifications of the original Nuss technique. Our technique for pectus excavatum repair can be used for successful repair of PE patient of all ages and is described to follow.

The impact of sex on the outcomes of treatment for locally advanced esophageal carcinoma is unclear. This study analyzed the impact of sex on response to neoadjuvant chemoradiotherapy (nCRT), tumor recurrence, and survival.From January 1990 through December 2013, female patients who received nCRT followed by esophagogastrectomy at 3 affiliated centers were compared with control male patients based on age, pretreatment clinical stage, histologic type, and surgical era. Only patients staged preoperatively with computed tomographic scans and endoscopic ultrasonography (EUS) were included.There were 366 patients (145 women and 221 men). The median female age was 64 years (range, 22-81 years), whereas male patients were 61 years (range, 33-82 years). The histologic type was adenocarcinoma in 105 (72%) women and 192 (87%) men, and it was squamous cell carcinoma in 40 (28%) women and 29 (13%) men (p = 0.005). Women were more likely to attain either a complete pathologic (CP) response or a nearly complete pathologic (NCP) response to induction therapy (84 [58%]) compared with men (103 [47%]; p = 0.034). Men had an 80% increased risk of recurrence (hazard ratio [HR], 1.80; 95% CI, 1.15-2.68; p = 0.008). There was no sex association with risk of death (p = 0.538). Irrespective of sex, a partial responder (relative to a complete or nearly complete responder) was 3 times more likely to have recurrence (HR, 2.96; 95% CI, 1.98-4.43; p0.001) and 2.5 times more likely to die (HR, 2.56; 95% CI, 1.88-3.48; p0.001).Female sex correlated with improved rates of achieving either a CP response or an NCP response after neoadjuvant chemotherapy and a smaller likelihood of experiencing tumor recurrence. Future efforts should be directed at understanding determinants of this sex disparity.

The Nuss procedure for repair of pectus excavatum involves the placement of substernal support bars that remain in place for 2 to 3 years. There are concerns about occlusion of the internal mammary artery due to the intrathoracic bars. It would be optimal to preserve one or more internal mammary arteries with the pectus repair. This report describes a 28-year-old man with severe symptomatic pectus excavatum who underwent Nuss repair. Robotic left internal mammary artery takedown was performed at the intercostal spaces planned for Nuss bars to prevent occlusion or damage from the bars.

PATIENTS WITH BRONCHIAL FISTULAS, including bronchopleural, bronchomediastinal, bronchopericardial, or bronchoesophageal, may present with significant difficulties in airway and ventilatory management. Fistulas are an infrequent, but well-described complication, of metal airway stents, and in the setting of advanced malignancy, communication with the mediastinal or pericardial space may occur. When these fistulas are present, positive-pressure ventilation has a high likelihood of developing cardiac tamponade, which may be catastrophic if diagnosis and management are delayed. The authors present a rare case of stent migration and fistula formation into the pericardial space that presented with acute intraoperative hemodynamic and respiratory decompensation, which never has been described in the literature.

Pectus excavatum (PE) patients have been reported to have a high incidence of mitral valve prolapse (MVP) and regurgitation (MR). We reviewed our transesophageal echocardiographic (TEE) experience with PE and observations that the mitral valve (MV) leaflets have an unusually lateral coaptation point

This article describes contemporary methods of diagnosis and current treatment regimens for most pulmonary infections. Modern techniques used to improve diagnostic yield in pulmonary infection include bronchoscopy, ultrasound- and electromagnetic-guided endoscopy, transthoracic needle biopsy, and samples obtained with thoracoscopy. The spectrum of bacterial, mycobacterial, fungal, and viral pathogens implicated in pulmonary disease is discussed. Treatment strategies and guideline recommendations for antimicrobial selection are described for community-acquired, health care–associated, hospital-acquired, and ventilator-associated pneumonia, and for the most common fungal, mycobacterial, and viral infections. The state-of-the art in topical and aerosolized anti-infective therapy and an algorithm for managing hemoptysis are also presented.

Background Minimally invasive esophagectomy (MIE) has been performed using a variety of techniques evolving during the past decade. We present our initial experience and outcomes of patients undergoing transthoracic MIE using a circular end-to-side anastomosis created with the transorally directed EEA circular stapler OrVil (Covidien, New Haven, CT). Complications, including anastomotic leak and stricture occurrence, are reviewed. Methods A retrospective review evaluated consecutive patients undergoing MIE for esophageal cancer or related disease with intrathoracic end-to-side anastomoses using the transorally directed EEA circular stapler from December 2007 to May 2010. Medical records were reviewed for demographics, staging, neoadjuvant chemoradiotherapy, comorbidities, adjuvant therapy, complications, and survival. Results During this period, 51 consecutive patients (84% male; mean age, 65 years) underwent MIE. Neoadjuvant chemoradiotherapy was performed in 32 patients, and 4 had intraoperative radiotherapy. Mean operative time was 338 minutes (range, 211 to 565 minutes), including the 4 patients with intraoperative radiotherapy. Operative time improved with experience (excluding intraoperative radiotherapy) from a mean of 378 minutes (patients 1 to 14) to 300 minutes (patients 37 to 51). Median hospital stay was 11 days (range, 6 to 48 days). Anastomotic leaks occurred in 5 patients (9.8%). Postoperative deaths included 1 in-hospital (2.0%) and 2 (3.9%) after discharge. Stricture was diagnosed and treated in 7 patients (13.7%). Follow-up was a median of 12 months (range, 1 to 31 months). Conclusions Transthoracic MIE using an end-to-side anastomosis with the transorally directed EEA circular stapler resulted in acceptable stricture and leak rates with good outcomes comparable to published outcomes for open surgical resections.

Radiographic identification of an abnormal lesion in the esophagus routinely occurs during workup of patients with symptomatic dysphagia. Leiomyoma is the most common benign finding; however, plexiform leiomyoma, a distinctive but rare variant, follows an unusual pattern of growth which can be a challenging surgical resection. A review of indexed literature identified a single previous report. We contribute a second case of plexiform leiomyoma with a discussion of the clinical, radiographic, and pathologic characteristics, as well as the differential diagnosis for plexiform lesions.

Emergent mechanical support with transfer of patients in acute cardiopulmonary shock to specialty centers for definitive management is often required at non-transplant centers. An alternative approach to the traditional "hub and spoke" model is presented. A team of health care specialists from our hospital is deployed to the community hospital for stabilization, possible implantation, and transfer of patients to our tertiary care facility. Patient assessment can be made with intervention, allowing stabilization and safe transfer by our team to our institution. This method provides tertiary level care at the referring hospital and may improve survival for a sub-set of patients in the community hospital setting.

Minimally invasive repair of pectus excavatum (MIRPE) is performed by placement of substernal metal bars. Visualization across the mediastinum is compromised in severe defects, and cardiac puncture and aortic injury have been described. In adults with less chest wall flexibility, the bars require more force to rotate and intercostal muscle stripping may result, leading to bar malpositioning. We present a technique to elevate the sternum and facilitate adult MIRPE.

Coccidioidomycosis results from infection with Coccidioides species endemic to the southwestern United States. The mobile US population has resulted in incremental cases being found throughout the world. The fungal infection can result in pulmonary sequelae, including nodules, cavities, and complications requiring treatment by the thoracic surgeon.A retrospective chart review was conducted of 1,496 patients with coccidioidomycosis treated at our institution (January 1998 to December 2008) to identify those requiring surgery.Of the 1,496 patients, 86 (6%; mean age, 58 years [range, 18 to 81], 48 women) underwent operations. Radiographs revealed 59 nodules, 18 cavities, 2 infiltrates, and 7 complications of disease (e.g., effusion, pneumothorax, and empyema). Of the 86 patients, 40% underwent resection for persistent symptoms or disease progression despite adequate antifungal therapy. One third of the operations were performed by video-assisted thoracoscopic surgery. Morbidity, 21% (18 patients), and in-hospital mortality, 2% (2 patients), were greater after resection for cavitary lesions with resultant complications versus for nodular disease: 41% versus 12% (por = 0.002) and 8% versus 0% (p0.005). Prolonged air leaks or bronchopleural fistulas were the most common complications (13 patients). Postoperative antifungal therapy was administered to 42% of patients (89% of cavitary and complicated). There were no cases of recurrence at follow-up (mean, 24 months).Surgical intervention was indicated for only a few patients, most commonly for diagnostic dilemmas involving nodular disease, symptomatic nonresponsive cavitary disease, or complications. Prolonged air leaks were the main cause of morbidity. Resection should result in symptom resolution and long-term freedom from recurrence.

Background Indications for placement of implantable cardioverter-defibrillators (ICD) and pacemakers have expanded, and traditional transvenous implantation may not be feasible in patients with aberrant anatomy or venous obstruction. In these settings, successful lead placement has required innovative surgical approaches. A case series of successful placement of these systems in challenging patients is presented. Methods A 2-year retrospective study of patients undergoing placement of minimally invasive epicardial pacing leads or ICD coils was performed. Results Eleven patients underwent minimally invasive surgical placement of leads or coils. None were converted to open sternotomy. One required extension to minianterior thoracotomy. Causes of intravenous placement failure included aberrant anatomy with failure to access coronary sinus in 9 and venous occlusion in 2. Four patients had previous operations through a median sternotomy. Procedures included left video-assisted thoracoscopic (VATS) placement of a left ventricular epicardial lead in 8, left VATS conversion to minianterior thoracotomy left ventricular epicardial lead placement in 1, left VATS placement of ICD coil in 1, subxiphoid placement of a right ventricular epicardial lead in 1, subxiphoid ICD coil in 2, and subcutaneous ICD coil placement in 3. Mean hospitalization was 4.6 days. Postoperative hypotension and pulmonary edema occurred in 27% of patients. No patients died. Conclusions Conventional transvenous lead implantation may be difficult or impossible in some patients with aberrant or occluded venous access. Novel surgical approaches with the use of minimally invasive procedures can establish optimally functional pacing and ICD systems without sternotomy and low associated morbidity.

Coronary artery bypass graft surgery (CABG) is one of the most commonly performed major surgical procedures. However, patients having undergone CABG may experience neurological problems such as stroke, delirium, and cognitive difficulties. Observations suggest that these complications are caused by several synergistic factors, most prominently brain ischemia secondary to cerebral hypoperfusion and/or embolization of heterogeneous endovascular debris. Embolic signals are commonly detected during surgery using intraoperative transcranial Doppler monitoring. After surgery, magnetic resonance imaging of the brain may detect scattered areas of brain ischemia in patients with or without delirium. The large majority of these patients do not exhibit focal neurological deficits suggestive of ischemic stroke. We review the literature pertaining to postoperative encephalopathy, with emphasis on prevention, diagnosis, and treatment.

To determine the safety and results of laparoscopic resection of benign pheochromocytomas.We retrospectively reviewed the medical charts of all patients who underwent laparoscopic adrenalectomy for benign pheochromocytomas at all 3 Mayo Clinic sites between January 1, 1992, and December 31, 2001. Demographics, comorbidities, clinical presentation, imaging studies, biochemical findings, operative intervention, and outcome were examined. Long-term follow-up was obtained via chart review and/or by direct telephone contact with the patient or a relative.Twenty-four women and 23 men with a mean age of 53.1 years (range, 16-81 years) underwent attempted laparoscopic resection of pheochromocytomas. In 5 patients, the procedure was converted to open laparotomy because of bleeding (2), inadequate exposure (2), and adhesions (1). The mean tumor size was 4.3 cm. The mean operative time (181.8 vs 1405 minutes; P = .03), mean hospital stay (6.00 vs 2.64 days; P.001), and mean blood loss (340 mL vs 80 mL; P.001) were greater in patients who underwent open laparotomy vs those who underwent laparoscopic resection. All specimens were classified as benign. The mean follow-up was 41 months (range, 10-89 months). No patients experienced a recurrence or developed metastatic disease.In light of surgical and anesthesia expertise, laparoscopic resection of benign pheochromocytomas is safe and effective with resultant short hospital stays. A low threshold to convert to an open procedure reduces operative times and decreases potentially serious complications. Although there have been no recurrences to date, long-term follow-up is required for all patients, especially those with hereditary forms of pheochromocytomas.

The aorta, celiac axis, and iliac arteries are the most common inflow arteries used for renal revascularization. When these inflow vessels are diseased, the superior mesenteric artery (SMA) can be an alternative source of renal artery graft inflow. Previous reports have suggested that only an enlarged SMA should be used for this purpose, for fear of developing mesenteric ischemia. We report a patient who required renal artery revascularization with a saphenous vein graft from a normal-caliber SMA who did not develop subsequent mesenteric ischemia. The procedure was unique in demonstrating that the SMA can be used as a viable source of graft inflow even when it is anatomically normal.

Desmoplastic melanoma (DM) is a rare variant of malignant melanoma. A better understanding of the clinical course of DM will impact on its treatment.We reviewed the medical records of 59 patients with DM seen at the Mayo Clinics Scottsdale and Rochester since 1985.Thirty-seven (63%) patients were male with a mean age of 62.8 years. The mean DM thickness was 6.5 mm. A total of 23 patients (39%) experienced local recurrence (LR). LR correlated with positive, unknown, or1 cm margins. Fifty percent of patients who locally recurred subsequently developed metastatic disease. No patients were found to have positive nodal disease during ELND (16) or SLN biopsy (12). Only 1 patient (2%) developed delayed regional node metastases. Sixteen patients developed metastatic disease. The most common site was the lungs (81%).LR is a significant problem and correlates with an increased risk of systemic metastatic disease. With the rare occurrence of lymphatic spread, we recommend patients undergo SLN biopsy only. DM appears to preferentially metastasize to the lungs and should be targeted when evaluating the patient for metastatic disease.

Circulatory assist devices are an increasingly common method of treating patients with refractory cardiogenic shock. We describe a patient who was a heart transplant candidate with biventricular failure who underwent CardioWest total artificial heart-temporary (SynCardia Inc, Tucson, AZ) implantation with extracorporeal membrane oxygenation to manage the patient's subsequent respiratory failure. After respiratory and hemodynamic stabilization, the CardioWest total artificial heart-temporary served as a successful 62-day bridge-to-heart transplantation.

Reports documenting the cardiopulmonary significance of pectus excavatum are limited, and there remains a lack of consensus as to whether surgical repair can improve function. We present a case of pectus excavatum deformity and heart failure. Surgical repair was performed with significant improvement of performance and heart function.

Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.

improved durability and performance relative to previous VADs. Our major rationale for choosing the HeartWare HVAD was its relatively small size and ability to be contained within the pericardium, thus eliminating the potential need to create a pocket or rotate the pump configuration. In addition, the device’s integrated inflow cannula could decrease the chance of inflow obstruction related to the abnormal position of the ventricles in CC-TGA. TEE guidance ensured successful selection of the optimal insertion site for the VAD inflow cannula. In summary, we report a case of successful HeartWare HVAD implantation in a patient with CC-TGA to support the function of the RV (systemic ventricle).

Purpose Infection is common complication associated with significant morbidity and mortality after implantation of mechanical circulatory support (MCS) devices. Standardized infection prevention practices have not been established. Methods and Materials An international survey to investigate the current infection prevention (IP) practices with MCS was conducted through an electronic survey. Through an ISHLT mailing, 210 centers identified a representative to complete the survey managed by the Research Survey Center at Mayo Clinic. Data regarding pre, peri, and post-implantation practices was collected. Results Representatives from 56 centers have completed the survey by November 2012. 37 (66.1%) centers routinely evaluate for pre-implant bacterial colonization; 35 for MRSA by nasal swab, 14 for MSSA and 7 for resistant gram-negatives. Pre-implant IP included antiseptics (94.6%) and pre-op chlorhexidine bath (62.6%). Pre-implant antibiotics given within 1 hour (60%) included vancomycin (82.1%), rifampin (32.1%), ciprofloxacin (21.4%) and antifungal (47.3%). The majority report antimicrobials duration for 24-48h (56%). Operative techniques reported included placing velour driveline portion subcutaneously (78.2%) and contralateral placement of driveline exit from device (61.5%). In addition, most centers reported willingness to participate in future IP trials. Conclusions Common IP practices were reported in the majority of MCS centers though subtle differences exist. Future consensus building and design of multi-center intervention studies in MCS may be developed based on this survey.