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Background: Pretreatment clinical staging is used to decide the course of treatment in early-stage esophageal cancer. Few studies assess the effect of inaccurate clinical staging on oncologic outcomes., Methods: We queried the National Cancer Database to identify patients undergoing esophagectomy for clinical stage cT1bN0 esophageal carcinoma between 2010 and 2019. Patients were categorized as being upstaged if, on final pathology, they had histopathologic disease that would have warranted treatment with neoadjuvant therapy. The textbook oncologic outcome was defined as margin-negative resection, 15 lymph nodes examined, a hospital stay of <21 days, no unplanned 30-day readmission or mortality, and stage-appropriate use of neoadjuvant therapy., Results: In total, 916 patients met inclusion criteria; 378 (41.2%) had a pathologic stage that differed from their pretreatment clinical stage. By multivariable regression, factors associated upstaging included: presentation between 2015 and 2019 (odds ratio 1.92 95% confidence interval [1.19, 3.13]), delay to esophagectomy of >30 days (odds ratio 2.38 95% confidence interval [1.13, 5.57]), larger tumor size (>2 cm relative to <2 cm, odds ratio 2.73 95% confidence interval [1.72, 4.39]), and poorly differentiated histology (odds ratio 2.79 95% confidence interval [1.75, 4.49]). The rate of textbook oncologic outcome assuming reliable clinical staging was 43.8%; accounting for upstaging, the rate of textbook oncologic outcome was 22.5% (P < .001)., Conclusion: In patients with cT1bN0 esophageal cancer, tumor size and histology are associated with the risk of inaccurate pretreatment clinical staging. Inaccuracies in clinical staging impact the rate at which providers achieve optimal oncologic outcomes., (Copyright © 2023. Published by Elsevier Inc.)

Background: Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined., Methods: We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods., Results: A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection., Conclusion: In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival., (Published by Elsevier Inc.)

Objective: Pulsatile and nonpulsatile left ventricular assist devices are effective in managing congestive heart failure. Despite early evidence for clinical efficacy, the long-term impact of nonpulsatile flow on end-organ function remains to be determined. Our goal was to compare rates of gastrointestinal bleeding in nonpulsatile and pulsatile device recipients., Methods: In a retrospective review of 101 left ventricular assist device recipients (55 nonpulsatile, 46 pulsatile) from October 31, 2003, to June 1, 2007, at a single center, gastrointestinal bleeding was defined as guaiac-positive stool with hemoglobin drop requiring transfusion of at least 2 units of packed red blood cells. To assess bleeding risk outside the initial postoperative course, any patients with a device in place for 15 days or less was excluded., Results: Twelve nonpulsatile and 3 pulsatile left ventricular assist device recipients had gastrointestinal bleeding 16 days or longer after device implantation. The event rates were 63 events/100 patient-years for nonpulsatile devices and 6.8 events/100 patient-years for pulsatile devices (P = .0004). This difference persisted for bleeding occurring 31 days or longer after device implantation, with 46.5 events/100 patient-years for nonpulsatile devices versus 4.7 events/100 patient-years for pulsatile devices (P = .0028). Mortalities were similar between groups (15% nonpulsatile vs 17% pulsatile, P = .6965)., Conclusion: Patients with nonpulsatile left ventricular assist devices appear to have a higher rate of gastrointestinal bleeding events than do pulsatile left ventricular assist device recipients. Further prospective evaluation is needed to determine potential etiologies and strategies for reducing gastrointestinal bleeding in this population.

Objective: Cardiovascular disease is a common cause of morbidity and mortality in organ transplant recipients, and cardiac surgery has become more common in this population. We performed a retrospective study of kidney transplant recipients who underwent cardiac surgery over the past 10 years at our institution with an emphasis on evaluating postoperative outcomes., Methods: Seventy-four patients with previous abdominal transplants underwent cardiac surgery (93% coronary artery bypass grafting, 5.4% bypass grafting plus valve, and 1.4% valve) between 1995 and 2005. These recipients were compared with 895 adult nontransplant patients undergoing cardiac surgery between 2000 and 2005. Only kidney and kidney-pancreas recipients were included in the analysis (n = 70) because there were only 2 liver and pancreas alone transplants., Results: As compared with nontransplant patients, kidney transplant patients were younger (mean age 52.1 +/- 10 years vs 61 +/- 13 years; P < .001) and had an increased incidence of diabetes (92.9% vs 39.1%; P < .001), peripheral vascular disease (37.1% vs 19.1%; P < .001), chronic kidney insufficiency (73.0% vs 13.4%; P < 0.001), and unstable angina (44.8% vs 25.7%; P = .005) There was no difference between the two groups in the complication rate at 30 days after surgery, except that transplant patients were more likely to have postoperative kidney dysfunction (32.6% vs 6.1%; P < .001) and require hemodialysis (11.7% vs 1.1%; P < .0001). Thirty-day postoperative mortality was similar between groups (1.4% vs 2.9%; P = not significant). By multivariable analysis, preoperative congestive heart failure, nonelective surgery, prolonged cardiopulmonary bypass times, peripheral vascular disease, and lower creatinine clearance were significant risk factors for postoperative mortality; however, prior kidney transplant was not an independent risk factor for 30-day postoperative mortality., Conclusions: Despite their increased incidence of comorbid conditions, the postoperative outcomes of cardiac surgery in kidney transplant recipients are similar to those in the nontransplant population except for a higher incidence of kidney dysfunction in transplant patients.

Between January 1973 and February 1986, operations were performed on 120 consecutive patients having usual atrial arrangement (atrial situs solitus), concordant atrioventricular connection, and double-outlet right ventricle. The ages at operation ranged from 1 day to 44 years and the weights from 2.6 to 84 kg. Sixty-three patients had one or more palliative procedures. For those, the hospital mortality rate was 9.5%. Palliation was considered a definitive procedure in 13 patients. Ninety-three patients had a reparative operation, with a 26.9% early mortality rate. In the group who had complete correction, taken as a whole, the surgical outcome was significantly affected by the position of the ventricular septal defect and by the year of operation. The year of operation was the main factor that, by multivariate analysis, correlated significantly with the hospital mortality in those patients having a subaortic defect and spiraling great arteries (p less than 0.05). No difference was found among this group for those patients having the morphologic characteristics of tetralogy of Fallot. The change-over point from the Mustard to the arterial switch procedures was the event with the greatest effect on hospital mortality in patients with a subpulmonary ventricular septal defect (p less than 0.025). Two late deaths have occurred among the 21 patients who had palliative intervention only. Sixty of the 68 survivors with intracardiac repair have been followed up for a period of 2 to 184 months (median 44 months). There were five late deaths (8.3%). Eight patients underwent successful reoperation. All except three of the long-term survivors were in functional class I. Good early and long-term results can be anticipated for the intracardiac repair of double-outlet right ventricle when the ventricular septal defect is subaortic or doubly committed. The arterial switch operation has been demonstrated to be the optimal approach for double-outlet right ventricle with subpulmonary ventricular septal defect. Results in patients with noncommitted ventricular septal defect have remained poor.

Successful clinical double-lung transplantation after 5 1/2 hours of pulmonary ischemia is reported. Static hypothermic preservation with a high-volume, high flow rate-modified Collin's solution pulmonary artery flush was used. Excellent early and late pulmonary function demonstrates the efficacy of the technique that is described in detail. Lung transplantation remains limited by the lack of reliable methods of long-term storage of donor organs, but refinement of current techniques may soon allow its wider application.