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Objective The study objective was to evaluate the use of video-assisted thoracoscopic surgery for removal of pulmonary sequelae of the fungal infection coccidioidomycosis. Methods Retrospective chart review of all patients with pulmonary coccidioidomycosis treated surgically at our tertiary care center between January 1, 2009, and August 31, 2012. Results Of 2166 patients treated for pulmonary coccidioidomycosis, 58 (2.7%) (median age, 52 years [range, 18-84 years]) required surgical treatment. Surgical resection was performed for diagnosis (n = 28 [48%]); 17 with positive positron emission tomography findings); persistent or progressive symptoms despite antifungal therapy (n = 23 [40%]); or complications (n = 7 [12%] of cavity rupture/infection). Of 33 patients (57%) who had serology performed, 23 (70%) had positive results. Video-assisted thoracoscopic surgery was used for most (95%; n = 55) procedures, including 38 (67%) wedge resections, 14 (24%) segmentectomies, and 6 (11%) lobectomies; 4 patients also required additional decortication. Major (8%), including 1 death, and minor (12%) complications occurred in 12 patients postoperatively. Median hospitalization was 3 days (range, 1-8 days). Postoperative antifungal therapy was administered to 50% of patients for a median duration of 2 months. No patient had recurrent coccidioidomycosis at a median follow-up of 19 months. Conclusions Although rarely necessary for pulmonary coccidioidomycosis, surgical intervention may be indicated. Specific indications include refractory symptomatic disease and complications of the infection, such as cavity rupture. Excisional biopsies also may be required for diagnostic confirmation of indeterminate pulmonary nodules. With video-assisted thoracoscopic surgery, diagnostic and therapeutic intervention can be undertaken with a low risk of complications and shorter length of hospital stay.

We present a case of life-threatening hemorrhage occurring during Nuss bar removal without obvious cardiac or major vascular injury. A 19-year-old woman with marfanoid features had undergone a Nuss procedure 3 years earlier for a pectus index of 7.2. A lateral chest radiograph revealed erosion of the upper bar into the sternum. During surgery, a 3.5-L blood loss occurred after removal of the eroded bar. This case provided many opportunities to improve preparedness for bar removal.

Background Minimally invasive repair of pectus excavatum has become an established method for repair of pectus excavatum. Bar displacement or rotation remains the most common complication of this repair requiring return to the operating room. Methods Retrospective review of all patients at a single institution who underwent repair of pectus excavatum using FiberWire for bar stabilization between December 2009 and March 2013 was undertaken. Results 93 patients underwent minimally invasive pectus repair using FiberWire during the study period. The patients included 73 males and 20 females, with an average age of 14.6years (range 7–21years). Mean operative time was 102minutes (range 56–198minutes). No patients developed wound complications, two patients developed pain because of bar migration and required return to the OR, and no patients had recurrence of their pectus defect because of bar migration during the study period. Median length of follow-up was 17months (range 3–36months). Conclusion Stabilization of pectus bars using circumferential rib fixation with FiberWire at multiple points on both sides of the bar appears to be effective in preventing bar rotation and displacement, and requires minimal change to the operation as it has been previously described. Early experience shows a low rate of complications.

Background Minimally invasive esophagectomy (MIE) is accepted for resection of early esophageal cancers. The optimal surgical approach for more advanced disease is unknown. An evaluation of MIE in patients with advanced tumors having undergone neoadjuvant chemoradiotherapy (nCRT) is presented. Methods A retrospective review of patients with esophageal cancer who underwent MIE from November 2006 to November 2011 was performed Results In total, 96 consecutive patients underwent MIE for malignancy. Median age was 65 years (range 26 to 88), and 86% were male. Adenocarcinoma represented 87% of patients. Eighty-three percent of patients were staged IIa or higher and 62 (65%) patients received neoadjuvant chemoradiotherapy. Four (6%) patients additionally received intraoperative electron beam radiotherapy. Twenty-six (27%) patients received postoperative adjuvant therapy with 22 (85%) of these having also received neoadjuvant chemoradiotherapy. All cases were completed thoraco-laparoscopically except for 2 conversions to mini-laparotomy. Twelve (12%) cervical anastomoses and 84 (88%) thoracic anastomoses were performed. Median operative time was 326 minutes (range 193 to 567) and did not differ significantly between those with and without nCRT. Complete pathologic response was seen in 21 (34%) of the 62 patients receiving neoadjuvant treatment. Major and minor morbidities were experienced in 28% and 38.5% of patients. There were 2 (2%) in-hospital mortalities; 1 each having received or not received neoadjuvant therapy. At median follow-up 24 months (range 3 to 70 months), overall survival was 58% and 55 (57%) patients were alive without recurrence. Conclusions Minimally invasive esophagectomy is an acceptable surgical therapy for advanced-stage esophageal malignancies after nCRT without evidence for increased morbidity or mortality.

Cardiac allograft rejection and failure may require mechanical circulatory support as bridge-to-retransplantation. Prognosis in this patient group is poor and implantable ventricular assist devices have had limited success due to organ failure associated with the high dose immunosuppression required to treat ongoing rejection. We present a case from our institution and the world-wide experience utilizing the SynCardia CardioWest Total Artificial Heart (TAH-t; SynCardia Systems, Inc., Tucson, AZ, USA) for replacement of the failing graft, recovery of patient and end-organ failure with ultimate bridge to retransplantation. We present our experience and review of world-wide experience for use of TAH-t in this type patient.

Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.

110 Background: Anastomotic leaks can occur after esophagectomy and optimal management after minimally invasive esophagectomy (MIE) is not well defined. We reviewed endoscopic management of leaks after MIE in patients undergoing trimodality therapy at Mayo Clinic Arizona. Methods: Records of patients undergoing MIE from November, 2006 to February, 2015 were reviewed after appropriate IRB approval. Results: 148 patients underwent MIE including 136 (91.8%) thoracic and 12 (8.1%) cervical anastomoses. Clinically significant anastomotic leaks were observed in 13 (8.8%) patients with 2 (16%) cervical and 11 (8%) thoracic anastomosis at a median of 6.1 days (0-14). 11 (11%) patients treated with neoadjuvant chemoradiotherapy experienced esophageal leak and 2 who did not receive chemoradiotherapy (4%). For treatment of anastomotic leaks, 10 patients underwent VATS with pleural space irrigation and chest tube replacement, and 11 patients underwent stent deployment at the anastomosis for repair. Stents were placed such that the fistula/leak was in the fully covered portion with the greater portion of the stent residing in the esophageal remnant. Stents were removed at a mean of 54 days (28-114). In 2 patients, overgrowth into the stent body required stent-in-stent placement (fully covered) with removal of both stents. Stents were successful at sealing all leaks. Conclusions: Leaks after MIE represent a small, but significant, morbidity in MIE. The majority can be managed by endoscopic stent placement. Stenting is an effective management tool for postoperative leaks in locally advanced esophageal malignancies.

For more than 50 years, surgeons used traditional open surgical methods to correct pectus excavatum deformities. These techniques have undergone multiple modifications but involve resection of costal cartilages and mobilization of the sternum to an anterior position. Long-term postoperative complications are rarely published. Recurrence with lung herniation presents unique challenges. We report a technique to repair this condition in a patient with massive chest wall defect and residual excavatum deformity after open repair of his excavatum deformity.

Iatrogenic pneumothorax has become an increasingly recognized complication of routine outpatient procedures, such as transthoracic needle biopsies of the lung and transbronchial lung biopsies. Patients with clinically significant pneumothorax are typically managed with evacuation via a percutaneously placed catheter or chest tube. Tube thoracotomy and chest tube management have traditionally been performed by cardiothoracic surgeons; however, with the increasing number of interventional radiologists and interventional pulmonologists, more chest tubes are being placed by specialists who do not admit and manage patients in the hospital setting. The responsibility for the admission of these patients to the hospital service has fallen to the internist. Hospitalists caring for such patients are often expected to manage the chest tube. General internal medicine training and the existing medical literature provide few guidelines to assist with this issue. We present a discussion of the current published literature and our management algorithms for hospitalists caring for patients admitted with iatrogenic pneumothorax.

Objective: 1) Demonstrate a novel method to repair a full thickness tracheal wall laceration. 2) Discuss the relationship of this new technique in regard to current accepted methods of treatment reported in the literature. 3) Learn that full thickness tracheal tears, although rare, are possible following routine tracheal balloon dilation.Method: We review a patient’s case of symptomatic idiopathic subglottic stenosis. One year after initial dilation, balloon dilation was performed and an 8-cm full-thickness tracheal laceration occurred. We report successful repair with a covered tracheobronchial stent and review the literature relating our repair to other accepted techniques.Results: Following tracheal balloon dilation, staying within recommended limits, a complete tear was identified. Using flexible endoscopy and fluoroscopic guidance the tear was measured to be 8 cm. An 80 × 20 mm covered tracheobronchial stent was deployed into position to overlie the area of tracheal disruption. Intraoperative compute...

Background Costal cartilage excision is an effective treatment of slipping rib syndrome (SRS), although the diagnosis of SRS may be elusive. We review our experience with SRS in the pediatric patient. Methods This is a retrospective review from 2000 to 2011 of patients presenting with symptoms of SRS before 18 years of age. Results Seven patients were identified who were diagnosed with SRS and underwent costal cartilage excision. All patients presented with unilateral chest pain that was exacerbated by activity. Five patients reported a popping or clicking sensation with activity that was associated with pain. On physical examination, all patients had reproducible pain with palpation over the affected cartilage. Four patients had a mobile or popping rib with palpation, and 4 also had chest wall asymmetry. Five patients underwent imaging, and 4 patients were referred to specialists. It was a median of 2 years (0-5 years) from onset of symptoms to resection. At resection, all cartilages were grossly abnormal. There were no postoperative complications. Follow-up was complete for all patients over a median 0.9 years (0.2-2.0 years). One patient had recurrence of pain in a different location; another had persistent pain, which was less severe. Conclusions Slipping rib syndrome presents with costal cartilage pain that is reproducible on physical examination and commonly associated with a mobile rib. Excision of the affected cartilage(s) is an effective treatment and should be considered early to avoid unnecessary diagnostic tests and evaluation, which delay definitive therapy.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is being recognized with increasing frequency. Diagnostic and treatment information is limited. A systematic review is presented, focusing on patient demographics, clinical presentation, diagnosis, treatment options, and outcomes. A systematic electronic literature search was conducted for adult DIPNECH cases reported in the English literature during the past 6 years. Twenty-four DIPNECH cases were identified. Another case from our institution is contributed. Women represent 92% (23 of 25). Mean age at diagnosis was 58 years (range, 36-76 yr). Most were nonsmokers (16 of 24). Symptoms included cough (71%), dyspnea (63%), and wheezing (25%) occurring days to years before diagnosis. Pulmonary function testing showed obstructive ventilatory disease in 54%. Lung nodules were seen in 15 patients (63%), ground-glass attenuation in 7 patients (29%), and bronchiectasis in 5 patients (21%). Histological confirmation required surgical lung biopsy for 88%; however, transbronchial biopsies alone were diagnostic in three patients. Treatments strategies included systemic and inhaled corticosteroids, bronchodilators, and lung resection. Available follow-up data in 17 patients showed 6 clinically improved, 7 who remained stable, and 4 clinically deteriorated. The majority of patients presenting with DIPNECH are middle-aged females with symptoms of cough and dyspnea; obstructive abnormalities on pulmonary function testing; and radiographic imaging showing pulmonary nodules, ground-glass attenuation, and bronchiectasis. In general, the clinical course remains stable; however, progression to respiratory failure does occur. Long-term follow-up and treatment remains incomplete. Establishment of a national multicenter DIPNECH registry would allow formulation of optimal evidence-based guidelines for management of these patients.

Introduction Constrictive pericarditis is a heterogeneous disease with many causes. Traumatic hemopericardium is an uncommon initiating cause. We report the case of a man developing constrictive pericarditis after blunt chest trauma, in order to highlight an approach to diagnosing the condition and to raise awareness of the possibility of this condition developing after blunt trauma. Case presentation A 72-year-old Caucasian man presented initially to our outpatient clinic with a one-year history of progressively worsening dyspnea, and recent onset of edema of the legs. He was later taken to the emergency department and admitted to hospital. He had previously received unsuccessful treatment from his local primary physicians for suspected respiratory disorder and cellulitis of his legs. Echocardiography showed evidence of pericardial constriction, and computed tomography revealed nodular, lobulated thickening of the pericardium and pleura bilaterally. Interventional biopsies were taken, but gave inconclusive results. Thus, as pericarditis and/or advanced malignancy were suspected, diagnostic video-assisted thoracoscopic surgery was performed to take biopsies from the abnormal lung and pericardial tissue. Examination of these supported the diagnosis of pericarditis, as acute and chronic inflammation and fibrous thickening were found, with no evidence of malignancy. Our patient underwent cardiac catheterization, which revealed three-vessel coronary artery disease. Emergency total pericardiectomy and coronary bypass were performed. Having excluded other common initiating factors, we considered that a blunt trauma that our patient had previously sustained to his chest was the potential cause of the constrictive pericarditis. Conclusion This was an interesting case of blunt chest trauma followed by progressive pericardial and pleural thickening. Subsequent development of chronic constrictive pericarditis occurred, requiring treatment by surgical pericardiectomy, as the clinical course of constrictive pericarditis is usually progressive without surgical intervention. Diagnosis of constrictive pericarditis remains challenging. Although uncommon, blunt trauma should be considered as a possible initiating cause. Delayed presentation of constrictive pericarditis should also be considered as a possible morbidity in a patient who has sustained blunt chest trauma. Our case also highlights the importance of performing echocardiography promptly in patients experiencing ongoing symptoms of congestive heart failure to allow earlier diagnosis of constrictive pericarditis or other cardiac disorders, and avoid unnecessary treatments.

Antibody-mediated rejection (AMR) (humoral rejection) of cardiac allografts remains difficult to diagnose and treat. Interest in AMR of cardiac allografts has increased over the last decade as it has become apparent that untreated humoral rejection threatens graft and patient survival. An international and multidisciplinary consensus group has formulated guidelines for the diagnosis and treatment of AMR and established that identification of circulating or donor-specific antibodies is not required and that asymptomatic AMR, that is, biopsy-proven AMR without cardiac dysfunction is a real entity with worsened prognosis. Strict criteria for the diagnosis of cardiac AMR have not been firmly established, although the diagnosis relies heavily on tissue pathological findings. Therapy remains largely empirical. We review an unfortunate experience with one of our patients and summarize recommended criteria for the diagnosis of AMR and potential treatment schemes with a focus on current limitations and the need for future research and innovation.

Pectus excavatum (PE) is a posterior depression of the sternum and adjacent costal cartilages accounting for more than 90% of congenital chest wall deformities.1,2 With inward compression and decreased chest volume, PE can be more than a cosmetic deformity. Severe cases frequently result in exercise intolerance and physiologic cardiopulmonary impairment. Often patients with PE are dismissed by their physicians as having an inconsequential cosmetic problem. This misconception has resulted in many patients reaching adulthood with uncorrected severe defects. With the advent of internet-based information sources and the lure of less invasive repair techniques, many adult patients with uncorrected PE are now seeking surgical repair. There is some evidence that a true physiologic impairment associated with the defect may worsen as the patient ages. Cardiopulmonary symptoms may develop in the adolescent; however, others may only develop symptoms with aging. The physiologic data documenting improved cardiopulmonary function and psychosocial function after repair in adults is limited by small sample sizes. Although many studies and a meta-analysis now support repair of PE in the adolescent, only a few studies in adults document physiologic impairment. This chapter reviews the available adult literature regarding treatment of PE in the adult patient.

The standard of care for resectable gastric or gastroesophageal (GE) junction cancer for patients who can tolerate a surgical procedure is surgical resection, but surgery alone is not optimal treatment for patients at high risk for relapse. For patients with lower-risk lesions (confined to gastric wall, nodes negative; T1-2N0M0), local-regional relapse risks are low, and adjuvant radiotherapy is usually not recommended, except in select instances. Since both local-regional and systemic relapses are common after resection of high-risk gastric or GE junction cancers (beyond wall, nodes positive, or both; T3-4N0, TanyN+), adjuvant treatment is indicated for these patients. The results of phase III trials that demonstrate a survival benefit for adjuvant preoperative radiotherapy, postoperative chemoradiation, or preoperative chemoradiation vs. surgery alone will be presented and compared with the results of adjuvant perioperative chemotherapy. Results of Surveillance, Epidemiology, and End Results (SEER) analyses and meta-analyses that support the role of adjuvant radiotherapy or chemoradiation will be summarized.

Large posterior mediastinal goiters are extremely rare. Progressive enlargement and possible compression of adjacent structures, as well as malignant potential necessitate that these goiters should be surgically excised. A review of mediastinal tumors, specifically intra-thoracic goiters is presented along with a case report of acute respiratory compromise secondary to tracheal compression by a large posterior goiter.

Fulminant myocarditis with rapid onset of symptoms and hemodynamic compromise is a rare indication for mechanical support. Because of the potentially reversible nature of this illness, advanced mechanical circulatory support is warranted to achieve recovery or as a bridge to transplantation. Circulatory device options currently available allow for a phased implementation of support modalities in a manner that reduces costs and patient risk. We present a patient with fulminant myocarditis where extracorporeal membrane oxygenation (ECMO) support escalated to short-term Levitronix CentriMag (Levitronix, Waltham, MA) biventricular assist devices (BiVADs). These in turn were exchanged, without major surgery, to long-term paracorporeal VADs (Thoratec, Pleasanton, CA). After rehabilitation and nearly total recovery, the patient was weaned from mechanical circulatory support after 104 cumulative days.

Cardiac allotransplantation has, over the years, become the established therapeutic modality for patients with end-stage heart failure. Significant advances in immunosuppressive therapy have dramatically improved the outcome of heart transplantation over the past four decades. This review will focus on the anaesthetic challenges involved in the perioperative management of these complex patients as well as some of the proposed alternatives to transplantation.

End-stage renal failure is often considered a relative contraindication for total artificial heart implantation due to the increased risk of mortality after transplantation. We report the successful treatment of a patient having heart and renal failure with the CardioWest (SynCardia Inc, Tucson, AZ) total artificial heart for bridge-to-cardiac transplantation of a heart and kidney.

Background VATS has become a preferred method for benign surgical conditions, yet still remains controversial for malignancies. The purpose of this study was to review our results of pulmonary metastasectomies using both conventional open thoracotomy and VATS techniques. Methods This is a retrospective chart review of pulmonary metastasectomies performed from 1986 to 2006. The surgical approach used for the initial pulmonary metastasectomy was either open thoracotomy or VATS. Main outcomes were overall survival and recurrence free survival, evaluated using Kaplan Meier analysis. A non-inferiority margin was set at 0.2. Results A total of 280 surgical procedures were performed on 186 patients. From 171 eligible individuals, 135 patients were treated with thoracotomy (82 M, 53 F; median age 49 years), and 36 with VATS (18 M, 18 F; median age 58.5 years). Primary cancers were mainly: 81 sarcoma (47%), 26 colorectal adenocarcinoma (15%) and 22 renal cell carcinoma (13%). Median postoperative follow was 26.2 months. The conversion rate was 10.3% and there were no cases of pleural cavity seeding. The 5-year overall survival rates were 58.8% for thoracotomy and 69.6% for VATS, with median overall survival of 53.2 months and 30.1 months, respectively (p = 0.03). The estimated difference in 5-year overall survival was 10.8%. Second occurrences were noted in 59 thoracotomy and 10 VATS patients. The 5-year recurrence free survival rates were 51% in thoracotomy and 67% in VATS (p = 0.27), with median recurrence free survival of 24.8 months and 25.6 months, respectively. Conclusion In cases of pulmonary metastases, VATS is an acceptable alternative that is both safe and efficacious. Non-inferiority analysis of 5-year overall survival demonstrates that VATS is equivalent to thoracotomy. VATS patients also have a longer recurrence free survival. Based on our experience, it is permissible to use VATS resection in these circumstances: small tumor, fewer nodules, single lesion, age ≤ 53, unilateral, tumor size amenable to wedge resection, and non-recurrent disease.

Fifty years ago, esophageal perforation was common after rigid upper endoscopy. The arrival of flexible endoscopic instruments and refinement in technique have decreased its incidence; however, esophageal perforation remains an important cause of morbidity and mortality. This complication merits a high index of clinical suspicion to prevent sequelae of mediastinitis and fulminant sepsis. Although the risk of perforation with esophagogastroduodenoscopy alone is only 0.03%, this risk can increase to 17% with therapeutic interventions in the setting of underlying esophageal and systemic diseases. A wide spectrum of management options exist, ranging from conservative treatment to surgical intervention. Prompt recognition and management, within 24 hours of perforation, is critical for favorable outcomes.

Background Adenocarcinomas commonly metastasize to the lungs and can be resected using open thoracotomy or video-assisted thoracic surgery (VATS). This study reviews metastatic resections in primary adenocarcinoma patients, using both thoracotomy and VATS. We aim to compare long-term prognoses to test the efficacy and viability of VATS. Methods A retrospective review of primary adenocarcinoma patients who underwent resection of pulmonary metastases from 1990 to 2006 was carried out. Information was obtained by chart review. Endpoints analyzed were disease-free interval (DFI), survival time, and recurrence-free survival (RFS). Results In a total of 42 (16 male, 26 female; median age 58.5 years) primary adenocarcinoma patients, 21 patients underwent first pulmonary metastatic resection using VATS (7 male, 14 female; median age 57 years) and 21 using thoracotomy (9 male, 12 female; median age 59 years). Primary adenocarcinomas were mainly 27 colorectal (64%) and 11 breast (26%). Two VATS (10%) and three open patients (14%) had local recurrences of the original cancer. Median postoperative follow was 13.3 months [interquartile range (IQR) 4.5–32.8 months] for VATS and 36.9 months (IQR 19.3–48.6 months) after thoracotomy. Median DFI–1 was 22.3 months (IQR 13.5–40.6 months) for VATS patients and 35.6 months (IQR 26.7–61.3 months) for open patients. Second thoracic occurrences were noted in six VATS patients (median DFI–2 9.2 months), and in seven open patients (median DFI-2 21.5 months). Third thoracic occurrences were noted in one VATS patient (DFI-3 18.7 months) and in one thoracotomy patient (DFI-3 21.8 months). Odds ratio of recurrence showed 12.5% less chance of developing recurrence in VATS patients. Five-year RFS was 53% in VATS and 57% in thoracotomy patients. Conclusions VATS has become a viable alternative to open thoracotomy for resection of pulmonary metastases. In cases of primary adenocarcinoma, VATS showed no increase in number of thoracic recurrences, and comparable RFS. Short-term follow-up is encouraging; long-term follow-up will be needed to confirm these results.

Background Severe pectus chest deformities are common, often causing physiologic impairment. Patients who do not undergo repair during childhood often experience progressive worsening of symptoms during adulthood. There are few published reports regarding pectus repair in adults. Methods A retrospective review from January 1986 through January 2007 was performed on patients age 19 years and older, who underwent surgical correction of pectus excavatum (PE) or carinatum (PC) at one hospital. Results Adult patients, including 268 PE (84%), 41 PC (13%), and 11 with combined deformities (3%) underwent open repair with minimal cartilage resection and a temporary internal support strut. Ages ranged from 19 to 67 years (mean, 27). Patients experienced dyspnea, decreased endurance and tachypnea with mild exertion (99%), tachycardia (94%), and chest pain (69%). All patients reported worsening of symptoms during adolescence, which became more severe during adulthood. The mean severity score for PC and PE was 1.8 and 5.8, respectively (normal = 2.5). All patients experienced improvement in symptoms within four months after repair. Mean hospitalization was 2.9 days. Complications included pleural effusion (n = 8), pneumothorax (n = 4), and pericarditis (n = 2). Small localized protrusions persisted in eight patients. Four patients underwent repair of mild recurrent deformities. There were no deaths. Ninety-eight percent reported considerable improvement in exercise tolerance and indicated postoperative results as very good or excellent. Conclusions Uncorrected pectus deformities persist after childhood and often cause worsening symptoms with increasing age. Repair can be performed in adults with low morbidity, short hospital stay, and considerable improvement in physiologic function.

Objectives:1) Review the presentation, pathology, and treatment of rhabdomyomas. 2) Recognize the potential need for open resection with reconstruction as a treatment of benign laryngeal lesions in rare cases.Methods:A 67-year-old female presented with dyspnea and hoarseness. On examination she had a soft, mobile, centrally-located neck mass. Fiberoptic laryngoscopy revealed a large, submucosal supraglottic mass. Computed tomography (CT) showed a 3-cm supraglottic tumor with extralaryngeal extension. Needle aspiration suggested rhabdomyoma, confirmed by direct laryngoscopy with biopsy. She subsequently underwent awake tracheostomy, hemilaryngectomy, and reconstruction with aortic homograft. Pathology showed adult rhabdomyoma with representative large, polygonal cells with abundant cytoplasm, focal cross-striations, and occasional “strap” cells. Three weeks postoperatively she was decannulated and found to have a functional voice and swallow. After six months of follow-up she is without evidence of recurre...

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.

134 Background: Brain metastasis (BM) is an uncommon site of failure in patients (pts) with esophageal cancer (EC) with reported rates between 1-6%. EC pts are living longer with the wider adoption of trimodality therapy and, as with other malignancies, this may change the patterns of failure. We evaluated the incidence and outcomes of BM in EC at Mayo Clinic in Arizona. Methods: A retrospective review identified pts who developed BM from cancer of the esophagus or gastroesophageal junction. A total of 321 patients treated for stage I-IV EC (adenocarcinoma, n = 273; squamous, n = 46; small cell, n = 2) were identified between 1997 and 2012. Fisher’s exact test was used for comparisons. Actuarial survival was calculated using Kaplan-Meier analysis. Results: BM developed in 13 pts (4%), all of whom had adenocarcinoma. Nine pts initially presented with T3 and/or node-positive disease. Four pts presented with metastatic disease to other sites, but only 1 of this group was diagnosed with BM at initial presentation. The median time from initial diagnosis to BM detection was 12 months (range 0-40). All pts were symptomatic at diagnosis. BM was solitary in 6 pts, multiple in 6 pts, and unknown in 1 pt. The posterior fossa was involved in 9 pts. The brain represented the first site of failure in 9 pts. Treatment included surgical resection (n = 5), stereotactic radiosurgery (n = 4), and whole brain radiotherapy (n = 9). Median overall survival was 24 months from initial diagnosis and 5 months from BM detection. Among pts with adenocarcinoma, 3/119 (2.5%) were diagnosed between 1997-2006 compared to 10/154 (6.5%) between 2007-2012 (P = 0.1). Conclusions: The brain remains an uncommon site of failure among pts with EC. A recent series reported an incidence of BM in 13% of pts, raising the possibility of a changing failure pattern. In our series, BM was detected in only 4% of pts. Our study is suggestive of a trend towards increased incidence of BM in more recent years, although it did not reach statistical significance and could be a consequence of the retrospective nature of the study. Both series found BM limited only to pts with adenocarcinoma, and a possible association has been reported between HER-2 overexpression and BM in EC. Therefore, BM in EC may be an interesting area for future study.

158 Background: Esophageal cancer patients (pts) require multidisciplinary management involving thoracic and general surgeons, medical and radiation oncologists, gastroenterologists and psychiatrists. Pts navigate complex medical discussions and endure challenges to nutrition, body image, swallowing mechanics, energy level and weight, mood, and performance status. Coordination of care is complicated by multiple sites of pt entry, complex scheduling requirements, and incomplete information at multidisciplinary consultation. A nurse navigator to coordinate the patient experience may optimize treatment and improve outcomes, quality of life and patient satisfaction. Methods: The nurse navigator evaluates all pt records prior to initial appointment and coordinates scheduling, records acquisition, testing and specialty appointments. The nurse navigator serves as a liaison with pts throughout the course of care and provides a patient navigation book (PNB) as a central source for patient-directed information and record keeping. Benchmarks compared before and after creation of the nurse navigator position include: (1) time from appointment request to multidisciplinary evaluation and start of treatment; (2) completeness of medical records and data (scans, pathology slides); (3) patient awareness of support services for themselves and caregivers; (4) utilization of the PNB; (5) number and frequency of interim hospitalizations and emergency room visits; (6) patient, caregiver, and physician satisfaction. Results: From January to July 2012, 27 gastroesophageal cancer pts have been followed by the nurse navigator. Most of these patients remain on active treatment, hence benchmark analysis is ongoing. Metrics thus far suggest improvement in time to treatment start and awareness of patient resources, use of the PNB and patient satisfaction. Conclusions: Esophageal cancer pts undergo complex and toxic multimodality therapy with curative intent. A dedicated nurse navigator may improve the patient experience, optimize adherence to guideline based therapy and appropriate timeframes and provide continuity to pts undergoing multidisciplinary treatment.