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Medical students and general surgery residents often do not get exposure to cardiothoracic surgery (CTS) because of a decreased emphasis on CTS rotations during their training. The Southern Thoracic Surgical Association (STSA) began offering the Brooks Scholarship to medical students in 2010 and general surgery residents in 2014 to promote CTS. This study examines the impact of the scholarship.We examined the history of the award and how STSA administers the award. Next we examined the impact of the award by evaluating the number of medical students and residents who are tracked to complete a CTS program. Finally we performed an analysis of the academic output of the awardees who have completed or were tracked to complete a CTS program.The scholarship was developed to honor the memory of past STSA President Dr James W. Brooks. The award is administered through the STSA scholarship committee and provides medical students and residents funds to attend the STSA annual meeting and the opportunity to spend time with a mentor during the meeting. Eighty-eight percent of medical student recipients (21/24) and 100% of general surgery resident recipients (15/15) have completed or are on track to complete a CTS program. The 36 recipients going into CTS have published a total of 823 papers and 9240 articles have cited those papers.The STSA medical student and general surgery Brooks scholarship awards were associated with completing or pursuing a career in CTS. STSA should continue the Brooks scholarship to attract talented medical students and residents to CTS.

Surgical training has focused on the development of technical competency. Interpersonal and cognitive skills are essential to working as an interdisciplinary team, which translates into safety for the patient and well-being for the surgeon and colleagues. This article offers an "alternative" surgical curriculum topic list to augment the technical skill sets traditionally taught to trainees.

Background With the recent introduction of Integrated Cardiothoracic Surgery Residency Programs (IPs), limited data exist on unmatched applicants. We aimed to determine the dropout rate in individuals who applied for IP but did not match. Methods An online Institutional Review Board–approved survey was sent to current residents (n = 409), provided by the Thoracic Surgery Directors Association, to evaluate preferences and pathway to cardiothoracic surgery (CTS). Descriptive analysis was performed on quantitative data. Main Residency Match Data from 2008 to 2017 were collected. Results Of 250 respondents, 89 (36%) were in IPs. In the cohort, 110 (44%) applied for at least one IP, whereas only 10 of the remaining 140 CTS residents had contemplated applying. From written comments of those 140 residents, the most common reasons against applying for IP programs were (1) uncertainty of IP training/belief that general surgery offered more well-rounded training and (2) uncommitted to CTS as a medical student. Interestingly, 96% of IP residents were set on a cardiac career, whereas a larger proportion of 4/3 and traditional residents were interested in general thoracic (36%). According to the National Resident Matching Program, 147 individuals applied to IP programs from 2008 to 2011 and were unmatched. Only 20 of those individuals (14%), from our results, ended up in a CTS residency program. Conclusions Only a small percentage of applicants that did not match to an IP from 2008 to 2011 have ended up in CTS. As IPs continue to develop and improve, the concerns brought about by current CTS residents must be addressed to attract the next generation of exceptional surgeons.

OBJECTIVES: The tendency for patients with primary focal hyperhidrosis (PFH), characterized by excessive sweating, to experience psycho-social deficits is well documented. In addition, although endoscopic thoracic sympathectomy (ETS) effectively corrects PFH, its role in the psycho-social management of these patients remains unclear. Here, we examined changes in psychiatric symptomatology and psychotropic medication usage in PFH patients following ETS. METHODS: In total, 106 PFH patients underwent ETS and were compared against 213 matched controls. Information on psychiatric diagnosis and prescription was obtained through a retrospective chart review. Prospectively, PFH patients completed Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales to evaluate pre- and postoperative quality-of-life and psycho-social impairment. RESULTS: A significantly greater proportion of PFH patients had been prescribed psychotropic medication (37.7%) compared to controls (14.1%) despite no differences in the proportion of psychiatric diagnoses. Following ETS, 52.5% of the PFH patients who were using psychotropic medications reduced their prescription regimen, compared to only 10% of control patients (P

To assess the rate and effect of anastomotic leak among patients who undergo esophagectomy with either thoracic or cervical anastomosis after neoadjuvant chemoradiation.We conducted a retrospective cohort study using data from the National Surgical Quality Improvement Program Esophagectomy Data File. We included adult patients who underwent esophagectomy for esophageal cancer (2016-2017) after neoadjuvant chemoradiation. We used inverse probability of treatment weighted regression adjustment to compare 30-day anastomotic leak and mortality rates among patients with cervical or thoracic anastomoses. We accounted for confounding due to patient-, surgeon-, and procedure-related variables.Of the 908 patients who met inclusion criteria, 528 (58%) had a thoracic anastomosis and 119 (13%) experienced anastomotic leak. There was no statistically significant difference in leak rate for patients who underwent thoracic (12%) compared with cervical anastomoses (14%) in the inverse probability of treatment weighted regression adjustment analysis (P = .09). Although overall 30-day mortality was low (2.3%), it was significantly higher among patients who had an anastomotic leak (8.4% vs 1.4%; P .01). Among patients with a leak, there was no significant difference in length of stay, mortality, or type of required intervention for patients with cervical versus thoracic anastomoses.Anastomosis type does not affect leak rates or mortality after esophagectomy in patients who have undergone neoadjuvant chemoradiation. Patient risk factors and surgeon experience should determine the ideal surgical approach for each patient.

Background Limited data exist for pectus excavatum repair in adults. We reviewed outcomes in adult patients undergoing Ravitch or Nuss pectus excavatum repairs to determine whether there was a statistical difference in postoperative complications and recurrence between primary and redo operations. Methods Patients undergoing pectus excavatum repair between 2001 and 2018 were excluded if they were receiving a concurrent unrelated operation, aged younger than 18 years, or had less than 1 year of follow-up (for recurrence analysis). Postoperative complications were recorded based on procedure type (Ravitch/Nuss) and iteration of repair (primary/redo). Continuous patient data were compared using Student t tests for variables such as age, length of stay, estimated blood loss, body mass index, and number of bars inserted. Fisher exact or χ2 tests were performed for postoperative complications and recurrence rates between groups. Results Of 290 patients, there were no significant differences in postoperative complications or recurrence rates between all Nuss repairs (n = 237; P = .59) and all Ravitch repairs (n = 53; P = .48), redo Nuss repairs (n = 53; P = .26) and Ravitch repairs (n=26; P = .99), and primary (P = .26) and redo Nuss (P = .10) repairs or primary (P = .99) and redo Ravitch (P = .99) repairs. There were significant differences in age, length of stay, follow-up, bars inserted, and estimated blood loss between all Nuss and Ravitch repairs (P Conclusions Postoperative complication and recurrence rates were not statistically different between Nuss and Ravitch procedures of all types, suggesting either procedure may have utility in recurrent pectus excavatum. Further research may look to expand sample size and a prospective study investigating long-term outcomes.

Background The feasibility and efficacy of a web-based curriculum in supplementing thoracic surgical training was previously shown. However, the impact of curricular participation on validated knowledge tests remains unknown. We compared in-service training examination (ITE) results among trainees, stratified by curricular use. Methods The national online curriculum was implemented in August 2013. We retrospectively reviewed trainees who participated in thoracic surgical training programs in both 2012 to 2013 and 2013 to 2014. Scores from the 2013 and 2014 ITEs were obtained, and curricular usage data were collected from site analytics. Trainees were separated into three groups according to 2013 ITE scores; within each group, changes in score for high- versus low-volume users were compared. Results 187 trainees took the ITE both years, with exposure to the online curriculum during only the second year. High-volume users' scores trended toward greater improvement than scores of low-volume users (+18.2% versus +13.0%, p = 0.199). When stratified by 2013 score, the lowest scoring quartile improved substantially, and the highest scoring quartile improved modestly, regardless of curricular use. However, for those individuals who achieved mid-range scores in 2013, there was a trend toward much greater improvement in score with heavier use of the curriculum (+17.0% versus +7.0%, p = 0.094). Conclusions Among trainees who had access to the novel online curriculum during the second of 2 consecutive years, we evaluated the impact of curricular participation on ITE scores. The effect appears to be most pronounced in individuals with mid-range scores, in whom high curricular use led to the greatest improvement.

Previous "high-stakes" examinations by the American Board of Thoracic Surgery (ABTS) required remote testing, were noneducational, and were not tailored to individual practices. Given the ABTS mission of public safety and diplomate education, the ABTS Maintenance of Certification (MOC) examination was revised in 2015 to improve the educational experience and validate knowledge acquired.The ABTS-MOC Committee developed a web-based, secure examination tailored to the specialty-specific practice profile (cardiac, general thoracic, cardiothoracic, congenital) of the individual surgeon. After an initial answer to each question, an educational critique was reviewed before returning to the initial question and logging a second (final) response. Intraexam learning was assessed by comparing scores before and after reading the critique. Diplomate feedback was obtained.A total of 988 diplomates completed the 10-year MOC examination between 2015 and 2017. Substantive learning was demonstrated with an 18%, 17%, 20%, and 9% improvement in cardiac, general thoracic, cardiothoracic, and congenital final scores, respectively. This improvement was most notable among diplomates with the lowest initial scores. Fewer diplomates failed the new exam (1% vs 2.3%). Diplomate postexam survey highlighted marked improvements in clinical relevance (35% vs 78%), convenience (37% vs 78%), and learning (15% vs 45%). Over 80% acknowledged educational value, and 97% preferred the new format.The new MOC process demonstrates increased knowledge acquisition through a convenient, secure, web-based practice-focused examination. This approach provides feedback, identifies baseline knowledge gaps for individual diplomates, and validates new knowledge attained.

Objective We conducted a phase I trial of neoadjuvant nivolumab, a monoclonal antibody to the programmed cell death protein 1 checkpoint receptor, in patients with resectable non–small cell lung cancer. We analyzed perioperative outcomes to assess the safety of this strategy. Methods Patients with untreated stage I-IIIA non–small cell lung cancer underwent neoadjuvant therapy with 2 cycles of nivolumab (3 mg/kg), 4 and 2 weeks before resection. Patients underwent invasive mediastinal staging as indicated and post-treatment computed tomography. Primary study end points were safety and feasibility of neoadjuvant nivolumab followed by pulmonary resection. Data on additional surgical details were collected through chart review. Results Of 22 patients enrolled, 20 underwent resection. One was unresectable; another had small cell histologic subtype. There were no delays to surgical resection. Median time from first treatment to surgery was 33 (range, 17-43) days. There were 15 lobectomies, 2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, and 1 wedge resection. Of 13 procedures attempted via a video-assisted thoracoscopic surgery or robotic approach, 7 (54%) required thoracotomy. Median operative time was 228 (range, 132-312) minutes; estimated blood loss was 100 (range, 25-1000) mL; length of hospital stay was 4 (range, 2-17) days. There was no operative mortality. Morbidity occurred in 10 of 20 patients (50%). The most common postoperative complication was atrial arrhythmia (6/20; 30%). Major pathologic response was identified in 9 of 20 patients (45%). Conclusions Neoadjuvant therapy with nivolumab was not associated with unexpected perioperative morbidity or mortality. More than half of the video-assisted thoracoscopic surgery/robotic cases were converted to thoracotomy, often because of hilar inflammation and fibrosis.

With the impending shortage of cardiothoracic (CT) surgeons, much focus has been on increasing trainee interest, particularly at the medical student level. We aimed to determine the effect of participation in our Cardiothoracic Surgery Interest Group (CTSIG) on medical student attitudes regarding surgery, and especially CT surgery.An anonymous survey was administered at two time points to the current member list of our 2015 to 2016 CTSIG and repeated for the 2016 to 2017 academic year. A set CTSIG event schedule was developed with current CT faculty and included events every 1 to 2 months. Total CTSIG membership was 101 students. Descriptive analysis was performed on quantitative data.Of 73 preclinical students completing both pre/postsurveys, 62% (45) were male. Postsurveys demonstrated increased interest in surgery and CT surgery as a career, which was significantly greater than those reporting no change (p0.01 for both). Common factors mentioned as deterrents for a CT surgery career included lifestyle, length of training, and associated personality/culture. Events hosted by the CTSIG most frequently reported as increasing interest included lunches/dinners with CT surgery faculty (89%), a "Leadership in Surgery" event (58%), and an "Intro to CT Surgery and Q/A Session" hosted by a CT surgeon (51%).Establishing a CTSIG that includes preset events with exposure to CT surgery by shadowing and interaction with faculty in a relaxed setting has the ability to increase preclinical interest in CT surgery. More emphasis on advocacy is needed to clear up misconceptions about CT surgery to maintain recruitment of outstanding students in our CT surgery heritage.

Background The most common site of metastasis for soft tissue sarcomas (STSs) is the lung. In patients who are candidates for resection, metastasectomy improves survival. Debate remains, however, on approach and patient selection for surgery. Methods We retrospectively analyzed demographics, tumor characteristics, peri- and postoperative factors for 53 patients who underwent lung metastasectomy for STS from 1989 to 2013. Disease-free intervals (DFIs) and survival were determined. Kaplan–Meier estimates and log-rank test were used for comparison and survival analyses. Results Median overall survival (diagnosis to death or last visit) was 59.9 months (IQR: 118.5), with mean follow-up of 85.3 months (SD: 69.5). Post-lung metastasectomy survival was 82.9%, 52.2%, 28.3%, and 13.3% at 1, 3, 5, and 10 years, respectively. Age at diagnosis of less than 50 years ( p = 0.037), a low pathologic grade ( p = 0.040), and a DFI until metastasis of greater than 13.5 months ( p = 0.007) were significant predictors of improved survival. Conclusion Patients diagnosed at a younger age with low-grade tumors and those with a longer DFI prior to metastasis diagnosis gain the greatest survival advantage with surgery.

Web-based curricula provide login data that can be advantageously used to characterize and analyze study habits. We sought to compare thoracic surgical trainee In-Training Examination percentiles with regard to their study habits (ie, cramming), as characterized by curriculum login frequency to the national Web-based Thoracic Surgery Curriculum. Furthermore, we then aimed to characterize the curriculum login frequency of trainees as stratified by their performance on the In-Training Examination and their improvement on the In-Training Examination over subsequent years.We performed a retrospective review of trainees who accessed the curriculum before the 2014 In-Training Examination, with curriculum login data collected from site analytics. Scores were compared between trainees who crammed (≥30% increase in logins in the month before the In-Training Examination) and those who did not. Trainees were stratified on the basis of 2014 In-Training Examination percentile and improvement in percentile from 2013 to 2014 into high, medium, and low scorers and improvers.Of 256 trainees who took the 2014 In-Training Examination, 63 (25%) met criteria as crammers. Crammers increased total study sessions immediately before the In-Training Examination (P .001), but without impact on 2014 In-Training Examination percentile (P = .995) or year-to-year improvement (P = .234). Stratification by In-Training Examination percentile demonstrated that highest scoring trainees used the curriculum more frequently in the final month than medium-range scorers (P = .039). When stratified by extent of year-to-year improvement, those who improved the most accessed the curriculum significantly more often in the last month compared with baseline (P = .040). Moreover, those with greatest improvement logged in more in the final month than those with least improvement (P = .006).Increasing the frequency of study periods on the national Web-based thoracic surgery curriculum before the In-Training Examination may have a unique benefit to trainees who initially score low to allow them to significantly improve their subsequent year In-Training Examination performance.

Robotic thymectomy has been well described for the management of myasthenia gravis and thymic masses. Both short- and long-term safety and efficacy have been demonstrated. Surgical approaches vary, but the technique for thymic dissection and excision is universal.

Objective Clinical T2N0 esophageal carcinoma is a heterogenous disease frequently complicated by inaccurate staging. Incorrect staging may lead to suboptimal treatment for patients with unidentified local-regionally advanced disease. Therapeutic options for these patients remain controversial. We sought to evaluate the outcomes of patients with cT2N0 who underwent esophagectomy as either primary therapy or after neoadjuvant treatment. Methods This was a multi-institutional collaboration of 26 high-volume esophageal centers. Patients with complete staging who underwent elective resection from 2002 to 2012 were included. Three treatment groups were identified; primary esophagectomy, preoperative chemotherapy, and preoperative chemoradiation (CXRT). Pretreatment variables were explored for independent predictors of long-term outcomes. The primary esophagectomy subgroup was evaluated for stage migration. Results In total, 767 patients were evaluated; 35% (268) had preoperative therapy (195 CXRT, 73 chemotherapy). Staging accuracy was 14% (70/499), with pT 0 in 39% (195). Preoperative treatment modality (none, CXRT, chemotherapy) was not identified as a predictor of outcome (median survival 63, 70, 71 months, respectively, P = .956). Longitudinal tumor length >3.25 cm was predictive of pN+ for the primary esophagectomy cohort as well as adenocarcinoma histology only (odds ratio 2.2 and 2.4, respectively, P Conclusions Current treatment options for patients with cT2N0M0 do not reveal a comparative survival advantage to preoperative therapy. Pretreatment tumor length can identify a subgroup of patients at risk for understaging (pN+). The incidence of overstaging suggests that organ-sparing approaches (endoscopic resection) may play a future role in appropriately selected patients.

Background Since 2010, the Joint Council on Thoracic Surgery Education, Inc (JCTSE) has sponsored an annual "Educate the Educators" (EtE) course. The goal is to provide United States academic cardiothoracic surgeons (CTS) the fundamentals of teaching skills, educational curriculum development, and using education for academic advancement. This report describes the course development and evaluation along with attendee's self-assessment of skills through the first 5 years of the program. Methods The content of this 2½-day course was based on needs assessment surveys of CTS and residents attending annual meetings in 2009. From 2010 to 2014, EtE was offered to all CTS at training programs approved by the Accreditation Council for Graduate Medical Education. Course content was evaluated by using end-of-course evaluation forms. A 5-point Likert scale (1 = poor, 5 = excellent) was used to obtain composite assessment mean scores for the 5 years on course variables, session presentations, and self-assessments. Results With 963 known academic CTS in the United States, 156 (16.3%) have attended, representing 70 of 72 training programs (97%), and 1 international surgeon attended. There were also 7 program coordinators. Ratings of core course contents ranged from 4.4 to 4.8, accompanied with highly complementary comments. Through self-assessment, skills and knowledge in all content areas statistically improved significantly. The effect of the course was evaluated with a follow-up survey in which responders rated the program 4.3 on the usefulness of the information for their career and 3.9 for educational productivity. Conclusions The EtE program offers an excellent opportunity for academic CTS to enhance their teaching skills, develop educational activities, and prepare for academic promotion. With its unique networking and mentorship environment, the EtE program is an important resource in the evolution of cardiothoracic surgical training in the United States.

Esophageal achalasia is a chronic and progressive motility disorder that leads to massive esophageal dilation when left untreated. Treatment for achalasia is palliative and aimed to relieve the outflow obstruction at the level of the lower esophageal sphincter, yet protecting the esophageal mucosa from refluxing gastric acids. The best way to accomplish this goal is through an esophageal myotomy and partial fundoplication, with a success rate >90%. Progression of disease, treatment failure, and complications from gastroesophageal reflux disease cause progressive deterioration of the esophageal function to an end stage in about 5% of patients. The only chance to improve symptoms in this small group of patients is through an esophageal resection. This article will review the indications for esophagectomy in end-stage achalasia, present the different types of surgical approach and possibilities for reconstruction of the alimentary tract, and summarize the short-term and long-term postoperative results.

Background The purpose of this study was to assess the effect of human immunodeficiency virus (HIV) infection on postoperative survival among non-small cell lung cancer (NSCLC) patients. Methods A retrospective cohort study compared 22 HIV-infected lung cancer patients to 2,430 lung cancer patients with HIV-unspecified status who underwent resection at Johns Hopkins Hospital from 1985 to 2009. Subcohort comparative analyses were performed using individual matching methods. Results Thirty-day mortality rates did not differ between HIV-infected and HIV-unspecified patients. Survival rates for HIV-infected lung cancer patients were significantly shorter than for HIV-unspecified patients (median, 26 versus 48 months; p = 0.001). After adjustment, the relative hazard of mortality among HIV-infected NSCLC patients was more than threefold that of HIV-unspecified patients (adjusted hazard ratio, 3.08; 95% confidence interval: 1.85 to 5.13). When additional surgical characteristics were modeled in a matched subcohort, the association remained statistically significant (adjusted hazard ratio, 2.31; 95% confidence interval: 1.11 to 4.81). Moreover, HIV-infected lung cancer patients with CD4 counts less than 200 cells/mm 3 had shortened median survival compared with patients whose CD4 counts were 200 cells/mm 3 or greater (8 versus 40 months; p = 0.031). Postoperative pulmonary and infectious complications were also elevated in the HIV-infected group ( p = 0.001 and p p = 0.061). Conclusions The HIV-infected NSCLC patients have more postoperative complications, rapid progression to disease recurrence, and poorer postoperative survival. Optimizing immune status before surgery and careful patient selection based on diffusion capacity of lung for carbon monoxide may improve patient outcomes.

Background Survival outcomes of never smokers with non-small cell lung cancer (NSCLC) who undergo surgery are poorly characterized. This investigation compared surgical outcomes of never and current smokers with NSCLC. Methods This investigation was a single-institution retrospective study of never and current smokers with NSCLC from 1975 to 2004. From an analytic cohort of 4,546 patients with NSCLC, we identified 724 never smokers and 3,822 current smokers. Overall, 1,142 patients underwent surgery with curative intent. For survival analysis by smoking status, hazard ratios (HRs) were estimated using Cox proportional hazard modeling and then further adjusted by other covariates. Results Never smokers were significantly more likely than current smokers to be women (P Conclusions Our findings suggest that smoking status at time of lung cancer diagnosis has little impact on the long-term survival of patients with NSCLC, especially after curative surgery. Despite different etiologies between lung cancer in never and current smokers the prognosis is equally dismal.

Robotic thymectomy is an emerging treatment for myasthenia gravis. However, the Myasthenia Gravis Foundation of America clinical research standards have been infrequently adopted in the surgical literature.Twenty-six patients underwent robotic thymectomy for myasthenia gravis between 2003 and 2008, performed by a single surgeon using the da Vinci system (Intuitive Surgical; Sunnyvale, CA) through a four-port right-sided approach.Mean operative times were 68+/-25 minutes of robotic system activation and 127+/-35 minutes from incision to closure. There were no intraoperative or postoperative mortalities; the most common intraoperative complication was desaturation after single-lung ventilation, for which four procedures were converted to open. On histologic examination, there were five thymomas. The average follow-up after surgery was 26 months. Median preoperative and postoperative Myasthenia Gravis Foundation of America disease classifications were 2 and 0, respectively, reflecting a statistically significant decrease in symptoms (p0.01). Additionally, the average daily dose of cholinesterase inhibitor decreased by 63% postoperatively. Overall, 82% of patients improved and 18% were unchanged; no worsening disease was observed.Robotic thymectomy is a safe and efficacious treatment option for myasthenia gravis. There were no notable differences in patient demographics compared with previously published reports of open thymectomies. Furthermore, surgical and neurologic outcomes in this series compare favorably with conventional approaches in the literature. Of those with follow-up greater than 6 months, 82% of patients undergoing robotic thymectomy demonstrated significant clinical improvement postoperatively, indicating that this approach in concert with optimized medical management is an effective treatment for myasthenia gravis.

Objective We hypothesized that most relapses in patients with esophageal cancer having neoadjuvant chemoradiation therapy would occur outside of the surgical and radiation fields. Methods Recurrence patterns, time to recurrence, and median survival were examined in 267 patients who had esophagectomy after neoadjuvant chemoradiation therapy at Johns Hopkins over 19 years. Results Of 267 patients, 82 (30.7%) showed complete response to neoadjuvant therapy, with 108 (40.4%) and 77 (28.8%) showing partial response or no response, respectively. Recurrence developed in 84 patients (patients with complete response 18/82, 21.4%; patients with partial response 39/108, 36.1%; patients with no response 27/77, 35.1%; P = .055, respectively). Most patients had recurrences at distant sites (65/84;77.4%) regardless of pathologic response, and subsequent survival was brief (median 8.37 months). Median disease-free survival was short (10 months) and did not differ based on recurrence site for patients with partial response or no response, but was longer for patients with complete response with distant recurrence, whose median disease-free survival was 27.3 months (P = .008). By multivariate analysis, no other factor except for pathologic response to neoadjuvant therapy was associated with disease recurrence or death. Patients with partial response or no response were 1.97 and 2.23 times more likely to have recurrence than patients with complete response (P = .024 and P = .012, respectively). Conclusions Most esophageal cancer recurrences after neoadjuvant therapy and surgery are distant, and survival time after recurrence is short regardless of pathologic response. Fewer patients achieving complete response had recurrences, and distant recurrences in these patients manifest later than in patients showing partial response and those showing no response. Only pathologic response is significantly associated with disease recurrence, suggesting that tumor biology and chemosensitivity are critical in long-term patient outcome.

Scleroderma is a systemic, mixed connective tissue disease that can impact the lungs through pulmonary fibrosis, vascular remodeling, and the development of pulmonary hypertension and right heart failure. Currently, little is known about the molecular mechanisms that drive this condition, but we have recently identified a novel gene product that is up-regulated in a murine model of hypoxia-induced pulmonary hypertension. This molecule, known as hypoxia-induced mitogenic factor (HIMF), is a member of the newly described resistin gene family. We have demonstrated that HIMF has mitogenic, angiogenic, vasoconstrictive, inflammatory, and chemokine-like properties, all of which are associated with vascular remodeling in the lung. Here, we demonstrate that the human homolog of HIMF, resistin-like molecule (RELM)-beta, is expressed in the lung tissue of patients with scleroderma-associated pulmonary hypertension and is up-regulated compared with normal control subjects. Immunofluorescence colocalization revealed that RELM-beta is expressed in the endothelium and vascular smooth muscle of remodeled vessels, as well as in plexiform lesions, macrophages, T cells, and myofibroblast-like cells. We also show that addition of recombinant RELM-beta induces proliferation and activation of ERK1/2 in primary cultured human pulmonary endothelial and smooth muscle cells. These results suggest that RELM-beta may be involved in the development of scleroderma-associated pulmonary hypertension.

Complex esophageal reconstruction (CER) is defined as restoring esophageal continuity in a previously operated field, using a nongastric conduit, or after esophageal diversion. This study compares the outcomes of CER with non-CER (NCER), which uses an undisturbed stomach for reconstruction.This single-institution retrospective cohort study compares 75 CERs with 75 NCERs from 1995 to 2014 that were matched for cancer versus benign disease. Distributions of demographic characteristics, comorbidities, and complications were compared between CER and NCER. Odds of mortality at 30 and 90 days were calculated with logistic regression. Overall survival was illustrated with Kaplan-Meier method and Cox proportional hazards regression.Although patients were similar in age, sex, and preoperative comorbidities, more non-white patients underwent CER (p = 0.04). Most NCER patients had adenocarcinoma (44%) or Barrett's high-grade dysplasia (39%); most CER patients had other benign disease (44%) or squamous cell carcinoma (24%, p0.01). CER had statistically significantly higher rates of reoperation, pneumonia, infection, and gastrointestinal complications, and longer median length of stay than NCER. Odds of mortality for CER and NCER at 30 days (odds ratio [OR] 1.0, 95% CI: 0.1 to 16.3), 90 days (OR 2.6, 95% CI: 0.5 to 13.9) and overall (adjusted hazard ratio 1.56, 95% CI: 0.9 to 2.7) were not statistically significantly different.Compared with NCER, CER patients had higher rates of return to the operating room, more postoperative infections and gastrointestinal complications, and longer length of stay. However, 30-day, 90-day, and overall survival were similar. CER should be offered to patients with acceptable risks and anticipated long-term survival.

Background This study was performed to test the hypothesis that a history of other primary neoplasms before a lung cancer diagnosis increases the risk of subsequent malignancy. Methods Of 8363 lung cancer patients seen from 1978 to 2002, 881 (11%) had at least 1 previous nonlung primary malignancy. Charts were analyzed for the occurrence of subsequent malignancies. Results Lung cancer diagnosis in 881 patients consisted of 75% non–small cell, 12% small cell, and 13% other histologies. The median age was 66 years, with 56% male, 76% white, and 86% smokers. Of the 881 patients, 92% had no subsequent cancer (group 1), and 8% went on to experience the development of a new primary neoplasm (including lung) after their lung cancer (group 2). After adequate follow-up, the cumulative probability of developing a subsequent cancer did not differ markedly between those with and without a prior non–lung cancer diagnosis at 2 years (12% vs 10%) or 5 years (16% vs 15%). Group 1 patients had a significantly lower 1- and 5-year survival than group 2 patients (59% vs 48% and 29% vs 17%, respectively; P = .008). Although multivariate analysis suggested that stage, history of tobacco-associated neoplasm, and history of definitive surgical resection were important determinants in predicting long-term survival, a prior malignancy was not an independent risk factor in the development of subsequent malignancy. Conclusions The risk of developing a subsequent malignancy is very high in lung cancer patients with prior primary malignancies, but it is not markedly different from the risks experienced by patients with no prior malignancies.

From the Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication Feb 26, 2016; accepted for publication Feb 27, 2016. Address for reprints: Stephen C. Yang, MD, Department of Surgery, The Johns Hopkins Medical Institutions, 600 N Wolfe St, Blalock 240, Baltimore, MD 21287 (E-mail: syang@jhmi.edu). J Thorac Cardiovasc Surg 2016;151:1559-60 0022-5223/$36.00 Copyright 2016 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.02.060

Background The morbidity of lung transplantation is higher than other solid organ transplants. Little is known about the outcomes of patients who require pulmonary resection following lung transplantation. We reviewed our experience to evaluate and discern any variables affecting outcome of pulmonary resections performed following lung transplantation. Methods A retrospective review of the lung transplant database was performed. Data are presented as mean ± standard error (median). Results A total of 136 lung transplants (80 single lung transplants [SLT], 55 bilateral lung transplants [BLT], and 3 heart-lung transplants [HLT]) were performed from August 1995 to February 2002. Twelve pulmonary resections, 7 lobectomies, and 5 wedge resections were performed on 11 patients. The indication for lobectomy was infection in 5 of 7 lobectomies (3 fungal, 2 bacterial), mass in 1 of 7, and infarction in 1 of 7. The indication for wedge resection was native lung hyperinflation in 4 of 5 wedge resections and mass in 1 of 5. The native lung was resected in 3 of 7 lobectomies and 4 of 5 wedge resections. An allograft lobectomy was performed following 1 SLT and 3 BLT and a wedge resection was performed after 1 SLT. The mean time to pulmonary resection was 12.4 ± 3.9 (9.1) months. Survival postresection was 17.2 ± 5.8 (8.3) months and 5 of 11 patients are still alive. There were no bronchial stump leaks following lobectomy. Conclusions Major pulmonary resections can safely be performed following lung transplant. We recommend early intervention to optimize outcomes.

Bronchiolitis obliterans syndrome remains the leading cause of morbidity and mortality in the pulmonary transplant population. Previous studies show that macrolide antibiotics may be efficacious in the treatment of panbronchiolitis and cystic fibrosis. In the latter, azithromycin decreases the number of respiratory exacerbations, improves FEV1, and improves quality of life. We hypothesized that oral azithromycin therapy may improve lung function in patients with bronchiolitis obliterans syndrome. To test this hypothesis, we conducted an open-label pilot trial using maintenance azithromycin therapy in six lung transplant recipients (250 mg orally three times per week for a mean of 13.7 weeks). In this study, five of these six individuals demonstrated significant improvement in pulmonary function, as assessed by FEV1, as compared with their baseline values at the start of azithromycin therapy. The mean increase in the percentage of predicted FEV1 values in these individuals was 17.1% (p/= 0.05). In addition, the absolute FEV1 increased by 0.50 L (range -0.18 to 1.36 L). These data suggest a potential role for maintenance macrolide therapy in the treatment of bronchiolitis obliterans syndrome in lung transplant recipients.

Pulmonary eosinophilia is an uncommon problem in lung transplant recipients. We report the unique occurrence of two cases of pulmonary eosinophilia in pulmonary allografts for sarcoidosis. Both patients rapidly acquired bronchiolitis obliterans syndrome (BOS) after resolution of pulmonary eosinophilia. It is known that peripheral eosinophilia is a marker for pulmonary allograft rejection, but its potential in the pathogenesis of BOS is unclear.

Fibrous dysplasia causing thoracic outlet syndrome is rare. A 41-year-old woman presented with neurogenic thoracic outlet syndrome with imaging that demonstrated a large tumor of her proximal left first rib. Transaxillary excision was unsuccessful due to involvement of the subclavian vasculature and brachial plexus. Subsequent posterolateral thoracotomy and resection of her first rib revealed fibrous dysplasia. Thoracotomy should be considered in these cases for optimal vascular control and identification of thoracic outlet anatomy.

Background Medical student exposure to cardiothoracic surgery has been facilitated by many scholarship opportunities. This study reviews the long-term interest of students at our institution who have received such support. Methods After the first or second year of medical school, participants were selected to receive scholarships for clinical or research activities in cardiothoracic surgery ranging from 4 to 8 weeks in duration. These were funded by the American Association for Thoracic Surgery, Society of Thoracic Surgeons, Southern Thoracic Surgical Association, or a private family donor. Over time, each student's scholarship type, current interest in cardiothoracic surgery, and current education or career status was prospectively monitored in an institutional database. Results Since 1999, 45 students received scholarships. Eight (18%) were funded by the American Association for Thoracic Surgery, two (4%) by The Society of Thoracic Surgeons one (2%) by the Southern Thoracic Surgical Association, and 34 (76%) by private donors. The median follow-up of graduated students is 7 years. Of the 20 (44%) with an active current interest in cardiothoracic surgery, 2 are faculty, 1 is a fellow, 1 is in an integrated 6-year program, 11 are in general surgery residency and are planning to apply to cardiothoracic surgery fellowship, and the remaining 5 are in medical school and planning a cardiothoracic surgery career. Of all former medical students who received cardiothoracic surgery research scholarships and who have now made a career choice, 17.4% chose cardiothoracic surgery. Conclusions More than one-third of medical students who received scholarships in cardiothoracic surgery maintained their interest over time, and more than half maintained interest in a surgical field. Although long-term data are scarce, it remains critical to foster mentoring relationships with students over time to guide their career choices.

Objective Readmission after surgery is an unwanted adverse event that is costly to the healthcare system. We sought to evaluate factors associated with increased risk of readmission and to characterize the nature of these readmissions in patients who have esophageal cancer. Methods A retrospective cohort study was performed in 306 patients with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by esophagectomy at Johns Hopkins Hospital between 1993 and 2011. Logistic regression was used to identify factors associated with 30-day readmission. Readmissions were defined as inpatient admissions to our institution within 30 days of discharge. Results The median age at surgery was 61 years; the median postoperative length of stay was 9 days; and 48% of patients had ≥1 postoperative complication (POC). The 30-day readmission rate was 13.7% (42 of 306). In univariate analysis, length of stay and having ≥1 POC were significantly associated with readmission. In multivariate analysis, having ≥1 POC was significantly associated with a >2-fold increase in risk for 30-day readmission (odds ratio 2.35, with 95% confidence interval [1.08-5.09], P = .031) when controlling for age at diagnosis and length of stay. Of the 42 patients who were readmitted, 67% experienced POCs after surgery; 50% of patients who experienced POCs were readmitted for reasons related to their postoperative complication. The most common reasons for readmission were pulmonary issues (29%), anastomotic complications (20%), gastrointestinal concerns (17%), and venous thromboembolism (14%). Conclusions Complications not adequately managed before discharge may lead to readmission. Quality improvement efforts surrounding venous thromboembolism prophylaxis, and discharging patients nothing-by-mouth, may be warranted.

Liposarcomas of the esophagus are rare with only 19 cases reported in the English literature. We present a giant, well-differentiated liposarcoma of the esophagus with multiple pedunculated polypoid-like growths, which made it radiographically and pathologically noncharacteristic. We discuss the diagnostic dilemmas, clinical and pathologic findings, and surgical treatment.

Objective: The objective was to determine the course of the long thoracic nerve relative to the scapula as an aid to the prevention of proximal long thoracic nerve injuries. Methods: Eighteen fresh cadavers (7 male, 11 female) were studied. Each was sequentially placed in the transaxillary and posterolateral thoracotomy positions, and the distance of the long thoracic nerve from the scapular tip and anterior scapular border was measured. The measurements were made bilaterally; the mean, standard deviation, and 99% confidence interval were calculated for each position by gender. Results: Distances from the scapular tip to the long thoracic nerve are listed as mean/outer range: transaxillary thoracotomy, male 4.9/7.0 cm left, 5.2/7.5 cm right; female 4.3/5.0 cm left, 4.7/6.0 cm right; posterolateral thoracotomy, male 3.1/6.0 cm left, 4.5/5.1 cm right; female 3.2/4.5 cm left, 3.8/5.5 cm right. In all instances, the long thoracic nerve was furthest from the scapula at its tip. Conclusion: For patients positioned for a transaxillary thoracotomy, incision sites should be at least 7.5 and 6.0 cm anterior to the scapular tip for male and female patients, respectively. For patients in posterolateral thoracotomy positioning, incisions should be 6.0 and 5.5 cm anterior to the scapular tip for male and female patients, respectively. By using these anatomic guidelines, we believe that the incidence of iatrogenic proximal long thoracic nerve injury can be minimized. (J Thorac Cardiovasc Surg 1998;116:960-4)

u B o s s p e t r a a a a s t c a ver the last few years, there have been a number of articles about the problems facing our specialty, articularly with regard to attracting the best individuals nto our cardiothoracic training programs. In an excellent rticle entitled Why Become a Cardiothoracic Surgeon [1], icholas Kouchoukos commences the paper with: These are trying times for the specialty of cardiothoracic urgery.” He goes on to enumerate some of the factors ontributing to these difficult times: six to nine years of urgical training after medical school; difficulty in finding uitable jobs at the completion of training and then the ual factors of increased malpractice payments in comination with diminishing annual incomes. Several thoacic society presidential addresses in the last two years ave also presented the foregoing problems related to ttracting “the best and brightest” medical students to ur specialty. The supply/demand issue in our specialty as a major topic considered in the 2003 Society of horacic Surgeons’ presidential address by one of us WAB) [2]. We pointed out that the current semi-crisis in he cardiothoracic job market appears to be transient and e could be facing a shortage of cardiothoracic surgeons n 10 to 12 years. This prediction is based on a 2002 ardiothoracic Manpower Study reported by Dr Richard hemin that indicates that one-half of the current cardiohoracic surgeons will be retired in 13 years; this correponds to a median calendar year of 2011 [3]. More recently, Irving Kron discussed the current suply/demand issue in cardiothoracic surgery in his presiential address at the Southern Thoracic Surgical Assoiation meeting in November 2005 [4]. In his insightful resentation, Dr Kron indicated that because of our aging aby-boomer population, the US Medicare population ill double between 2000 and 2030, and this dramatic ncrease in our aged population will no doubt provide any new patients who will require surgical procedures or ventricular dysfunction, valvular pathology, and cornary and pulmonary disease processes. Dr Kron also redicted a shortage of cardiothoracic surgeons within he next 5 to 10 years. Certainly a shortage of cardiothoacic surgeons, even in the next 10 years, makes it mperative that we try to attract at this time, a large umber of highly qualified medical (and premedical) tudents to our specialty. Those of us in the Divisions of Cardiac and Thoracic

Background Cardiothoracic surgical education faces numerous challenges, including reduced duty hours and diminishing prioritization of teaching, in the setting of rapidly advancing knowledge, skills, and case complexity. Pass rates on the American Board of Thoracic Surgery exam remain suboptimal, and new training formats are being evaluated. We hypothesize that Internet-based courses can be developed and implemented to supplement learning of basic topics in cardiothoracic surgery. Methods After a needs assessment, 4 online self-study courses were developed by content experts using a Moodle [modular object-oriented dynamic learning environment] platform. As a pilot cohort, students from 4 thoracic surgery training programs participated, accessing courses at their own pace. Each course included general and detailed readings, multimedia content, discussion forum, and a question-bank supported quiz (90% required to pass, multiple attempts allowed). Utilization and exam data were tracked electronically. The t tests were used to compare first versus final-year traditional track trainees. Post-course surveys collected data on trainee attitudes. Results Nineteen students completed 4 courses on tracheal disease. Mean time spent per course and quiz attempts to pass were 1.35 hours and 2.86, respectively. Scores improved with successive attempts. Senior trainees showed a trend toward less time per course and fewer quiz attempts. Post-course surveys uniformly demonstrated perceived benefits from the content and quizzes in an easy-to-navigate format. Conclusions Online courses can be developed and integrated within cardiothoracic training programs. This pilot demonstrates evidence of active learning as shown through the embedded assessments. Internet-based courses may serve as a means of supplementing modern thoracic surgical training. Further development and evaluation are warranted.