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Background Surgical resection is the standard of care for patients with resectable non–small cell lung cancer or selected patients with pulmonary metastases. However, for high-risk patients radiofrequency ablation (RFA) may offer an alternative option. The objective of this study was to evaluate computed tomography–guided RFA for high-risk patients and report our initial experience in 100 consecutive patients by a thoracic surgical service. Methods Medically inoperable patients were offered RFA. Thoracic surgeons evaluated and performed RFA under computed tomography guidance. Patients were followed in the thoracic surgery clinic. The primary end point evaluated was overall survival. Results One hundred patients underwent image-guided RFA for lung neoplasm (40 men, 60 women; median age, 73.5 years; range, 26 to 95 years). Forty-six patients (46%) with primary lung neoplasm, 25 patients (25%) with recurrent cancer, and 29 patients (29%) with pulmonary metastases underwent RFA. The mean follow-up for alive patients was 17 months. The median overall survival for the entire group of patients was 23 months. The probabilities of 2-year overall survival for the entire group, primary lung cancer patients, recurrent cancer patients, and metastatic cancer patients were 49% (95% confidence interval, 37 to 60), 50% (95% confidence interval, 33 to 65), 55% (95% confidence interval, 25 to 77), and 41% (95% confidence interval, 19 to 62), respectively. Conclusions Our experience indicates that image-guided RFA done by the thoracic surgeons is feasible and safe in high-risk patients with lung neoplasm with reasonable results in patients who are not fit for surgery. Thoracic surgeons can perform RFA safely, and should continue to investigate this new image-guided modality that may offer an alternative option in medically inoperable patients.

Bochdalek hernia is a rare surgical condition primarily diagnosed in infants. Morgagni hernia is more commonly identified in adults. A subset of patients with a Bochdalek hernia, especially those with a right-sided defect, may also be diagnosed during adulthood. Both adult forms of CDH may be discovered incidentally or diagnosed as part of the investigation of nonspecific gastrointestinal or respiratory symptoms. It is recommended that all adult CDH patients undergo surgical repair to prevent incarceration and strangulation of abdominal viscera. Currently, many reports have demonstrated the safety and efficacy of using open or minimally invasive repairtechniques, with or without mesh reinforcement. Regardless of the approach selected, surgical repair has been associated with low morbidity and mortality and excellent long-term outcomes with low rate of recurrence.

Background The diagnostic yield and accuracy of new approaches to diagnose cancer should focus on comparison with established surgical techniques. Our objective was to evaluate the diagnostic performance of endobronchial ultrasound (EBUS) to detect cancer in patients with radiographically abnormal mediastinal lymph nodes. Methods The medical records of patients who underwent EBUS and had abnormal mediastinal lymph nodes (short-axis >1 cm and [or] positron emission topography-positive) over a 25 month period at the University of Pittsburgh were reviewed. Demographic and clinical data, cytology, and pathology results were entered in a database and analyzed. Results A total of 172 patients [male to female=1.8:1; median age, 67 years (range, 20 to 90]) were included. The diagnostic yield of EBUS cytology was 79.7% (137 of 172). Pathologic testing was available in 68% (117 of 172) and 82% (96 of 117) had a diagnostic EBUS. The diagnostic accuracy of EBUS was 91.7%. The sensitivity, specificity, positive (PPV) and negative (NPV) predictive values were 88.1% (95% confidence interval [CI], 77.3 to 94.3), 100% (95% CI, 85.9 to 100), 100% (95% CI, 92.4 to 100), and 80.6% (95% CI, 63.4 to 91.2), respectively. In 67 patients who had a suspected or biopsy-proven primary lung cancer, diagnostic yield was 86.6% and accuracy was 94.8%. In this subgroup the sensitivity, specificity, PPV, and NPV were 93% (95% CI, 76.5 to 98.9), 100% (95% CI, 69.9 to 100), 100% (95% CI, 85 to 100), and 83.3% (95% CI, 56.2 to 97.5). Conclusions Diagnostic performance data support the clinical usefulness of EBUS in the evaluation of patients with a radiographically abnormal mediastinum. It should be considered complementary to mediastinoscopy rather than substitutive.

Objectives Surgical resection is the preferred treatment in selected patients with pulmonary metastases. In high-risk patients, radiofrequency ablation (RFA) may offer an alternative option. RFA may be used alone or combined with surgical resection as a lung parenchymal-sparing approach. Our objectives were to evaluate the intermediate term outcomes after RFA and to determine the prognostic variables associated with outcome in patients with pulmonary metastases. Methods Thoracic surgeons evaluated and performed RFA under computed tomography (CT) guidance or combined with surgical resection. Patients were monitored in the thoracic surgery clinic for recurrence and survival. Results Twenty-two patients (10 men, 12 women; median age, 63 years [range, 37 to 88]) underwent RFA. The primary cancer was colorectal in 9 (41%), renal in 2 (9%), sarcoma in 4 (18%), and other in 7 (32%). CT-guided RFA was the sole treatment in 17 patients (77%) and combined with surgical resection in 5 (23%). No procedurally related deaths occurred. At a mean follow-up of 27 months (range, 13.3 to 53.6 months), 9 patients are alive. The median survival was 29 months (95% confidence interval, 9.1 to 33.8). Lesion size was an important prognostic variable associated with overall and disease-free survival ( p ω 0.05). Conclusions RFA is safe in this group of pulmonary metastases patients, with reasonable results. Surgical resection remains the standard for resectable patients, but RFA offers an alternative in selected patients or may be used as a parenchymal-sparing approach in combination with surgical resection in selected patients.

ObjectiveThe study objective was to determine the clinical usefulness and accuracy of endobronchial ultrasound-guided needle aspiration of mediastinal and hilar lymph nodes.MethodsA retrospective analysis of a thoracic surgery unit's experience was performed.ResultsIn a period of 19 months, 75 patients underwent the procedure (mean age = 65.5 ± 1.6 years; male to female = 2:1) most commonly for mediastinal lymphadenopathy in the setting of diagnosed or suspected lung cancer. It was diagnostic in 68.9% after rapid on-site evaluation and 74.3% after final cytologic examination. The rapid on-site evaluation and final cytology results were discordant in 16.2% (P < .001). In 50 cases, the needle aspirate cytology could be compared with pathology results. The sensitivity and specificity for the diagnosis of cancer were 85% and 100%, respectively. The false-negative rate endobronchial ultrasound cytology was 8.1%. Mediastinal lymph node station 7 was most commonly biopsied. The stations with the highest diagnostic yield were: 11R, 3, 10L, and 7. Of the patients with a positive positron emission tomography scan with suspected clinical stage III lung cancer, cancer was downstaged in 40% after endobronchial ultrasound.ConclusionEndobronchial ultrasound-guided needle aspiration is a clinically useful minimally invasive option for lung cancer staging and evaluation of mediastinal lymphadenopathy. The procedure should be considered complementary to mediastinoscopy.

Naturally derived extracellular matrix (ECM) scaffolds have been successfully used to promote constructive remodeling of injured or missing tissue in a variety of anatomical locations, including abdominal wall repair. Furthermore, ECM scaffolds have shown the ability to resist infection and adhesion formation. The present study investigated the utility of an ECM scaffold, specifically, porcine urinary bladder matrix (UBM), for repair of a 5 x 5 cm full-thickness lateral thoracic wall defect in a canine model (n = 6) including 5-cm segments of the 6th and 7th rib. The resected portion of the 7th rib was replaced as an interpositional graft along with the UBM scaffold. As a control, a Gore-Tex patch was used to repair the same defect (n = 2). The control animals healed by encapsulation of the Gore-Tex patch by dense collagenous tissue. The remodeled UBM grafts showed the presence of site-specific tissue, including organized fibrous connective tissue, muscle tissue, adipose tissue, and bone. Upon fluoroscopic examination, it was shown that both bony defects were replaced with new calcified bone. In the 6th rib space, new bone bridged the entire span. In the 7th rib space, there was evidence of bone formation between the interpositional graft and the existing bone, as well as de novo formation of organized bone in the shape of the missing rib segment parallel to the interpositional graft. This study shows that a naturally occurring ECM scaffold promotes site-specific constructive remodeling in a large thoracic wall defect.

Background The new generation of expandable plastic esophageal stents (Polyflex; Boston Scientific, Natick, MA), combine the features of plastic and self-expanding metallic stents. The main objective of this study is to evaluate our initial experience with Polyflex expandable stents in the treatment of esophageal disease from two institutions. Methods A total of 58 Polyflex stents were placed in 38 patients over a two-year period. There were 24 men and 14 women, with a median age of 63 years (range, 25 to 83). The most common indication for placement was an esophageal stricture in 25 patients (66%); other causes included leak in 8 (21%) and tracheoesophageal fistula (TEF) in 5 (13%). We evaluated the hospital course, complications, and outcomes. Results The median postoperative stay was one day. Complications included migration in 38 stents (63%) (28 patients; 73%), retrosternal chest discomfort in nine, reflux in four, airway obstruction in one, and food impaction in three. Continued leak or a persistent TEF occurred in five patients (38%). Reintervention was required predominantly due to migration of the stent at a mean interval of 46 days (range, 1 to 353). Patients with dysphagia improved significantly with dysphagia scores (1 = no dysphagia; 5=unable to swallow saliva) improving from 3.44 to 2.15 ( p Conclusions Polyflex stents were effective in the relief of dysphagia due to strictures. They were less effective in esophageal perforations or leaks. Their primary disadvantage is a high migration rate and further improvements in design are required to decrease this high incidence of migration.

Objective Surgical resection is the standard of care for stage I non–small cell lung cancer. The objective of this study was to evaluate computed tomography–guided radiofrequency ablation as an alternative treatment option for high-risk patients with stage I non–small lung cancer. Methods Patients with medically inoperable stage I non–small lung cancer were offered radiofrequency ablation. Thoracic surgeons evaluated and performed radiofrequency ablation under computed tomographic scanning guidance. Response was assessed by means of computed tomographic and positron emission tomographic scanning. Time to progression and survival were monitored every 3 months. Results Nineteen patients underwent radiofrequency ablation over a 3-year period. There were 8 men and 11 women with a median age of 78 years (range, 68-88 years). Radiofrequency ablation resulted in pneumothorax requiring a pigtail catheter in 12 (63%) patients. An initial complete response was observed in 2 (10.5%) patients, a partial response in 10 (53%) patients, and stable disease in 5 (26%) patients. Early progression occurred in 2 (10.5%) patients. During follow-up, local progression occurred in 8 (42%) nodules, and the median time to progression was 27 months. There were no procedure-related mortalities, and 6 deaths occurred during follow-up. The mean follow-up in the remaining patients was 29 months (range, 9-52 months). The probability of survival at 1 year was estimated to be 95% (95% confidence interval, 0.85-1.0). The median survival was not reached. Conclusion Our experience indicates that radiofrequency ablation is safe in high-risk patients with stage I non–small lung cancer, with reasonable results in patients who are not fit for surgical intervention.

Objective Health care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. Methods We performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. Results A total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). Conclusions Active management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection.

Background Using the thoracic morbidity and mortality classification to document all postoperative adverse events between October 2012 and February 2014, we created surgeon-specific outcome reports (SSORs) to promote self-assessment and to implement a divisional continuous quality improvement (CQI) program, on the construct of positive deviance, to improve individual surgeon's clinical performance. Methods Mixed-methods study within a division of six thoracic surgeons, involving (1) development of real-time, Web-based, risk-adjusted SSORs; (2) implementation of CQI seminars (n = 6; September 2013 to June 2014) for evaluation of results, collegial discussion on quality improvement based on identification of positive outliers, and selection of quality indicators for future discussion; and (3) in-person interviews to identify facilitators and barriers to using SSORs and CQI. Interview transcripts were analyzed using thematic analysis. Results Interviews revealed enthusiastic support for SSORs as a means to improve patient care through awareness of personal outcomes with blinded divisional comparison for similar operations and diseases, and apply the learning objectives to continuous professional development and maintenance of certification. Perceived limitations of SSORs included difficulty measuring surgeon expertise, limited understanding of risk adjustment, resistance to change, and belief that knowledge of sensitive data could lead to punitive actions. All surgeons believed CQI seminars led to collegial discussions, whereas perceived limitations included quorum participation and failing to circle back on actionable items. Conclusions Real-time performance feedback using SSORs can motivate surgeons to improve their practice, and CQI seminars offer the opportunity to review and interpret results and address issues in a supportive environment. Whether SSORs and CQI can lead to improvements in rates of postoperative adverse events is a matter of ongoing research.

OBJECTIVES The ability to accurately characterize a pulmonary air leak is an essential skill in chest medicine and surgery. The objective was to evaluate interobserver variability in air leak assessments using analogue and digital pleural drainage systems. METHODS Air leak severity in lung resection patients with a pulmonary air leak was prospectively evaluated by at least one thoracic surgeon, one surgical resident and one to two nurses using a standardized questionnaire. The first assessment was performed with pleural drains connected to an analogue system. Subsequently, patients were re-assessed after changing from the analogue to a digital drainage system. The thoracic surgeon's evaluation was considered the reference standard for comparison. Agreement between observers was quantified using the kappa (κ) statistic. RESULTS A total of 128 air leak evaluations were completed in 30 patients (thoracic surgeon = 30; nurses = 56; resident = 30; physiotherapists = 12). The mean time between analogue and digital assessment was 2.16 (±1.66) h. The level of observer agreement regarding air leak severity significantly increased from very slight to substantial when using the digital drainage system [analogue κ = 0.03; confidence interval (CI): 0.04-0.11; P = 0.40) (digital κ = 0.61; CI: 0.49-0.73; P < 0.01]. Similar improvements were observed in subgroups of health-care professionals using digital technology. CONCLUSIONS Digital pleural drainage technology improves the agreement level between members of the health-care team when assessing the severity of a pulmonary air leak after lung resection.

This systematic review and meta-analysis was performed to determine whether timing or type of tracheostomy was associated with superficial or deep sternal wound infections after cardiac surgery.All studies reporting the incidence of sternal wound infection after tracheostomy in patients undergoing cardiac surgery were collected and analyzed. Subgroup analyses determined a priori included timing of tracheostomy and type of procedure (open vs percutaneous). All analyses used the random effects model. A meta-regression analysis was performed on the proportion of sternal wound infection and number of days between tracheostomy and initial cardiac surgery.A total of 13 studies met inclusion criteria. The incidence of sternal wound infection across all studies reported was 7% (95% confidence interval [CI], 4-10). The percutaneous tracheostomy group had a sternal wound infection proportion of 3% (95% CI, 1-8), and the open tracheostomy group had a sternal wound infection proportion of 9% (95% CI, 5-14). The incidence of sternal wound infection with early (14 days) (7%; 95% CI, 3-11) versus late (≥14 days) (7%; 95% CI, 4-10) tracheostomy was similar. Meta-regression demonstrated no significant relationship between incidence of sternal wound infection and number of days between tracheostomy and initial cardiac surgery (RThe incidence of sternal wound infection after tracheostomy in patients undergoing cardiac surgery remains high at 7% (95% CI, 4-10). Open or percutaneous tracheostomy after cardiac surgery is a feasible option because the incidence of sternal wound infection and short-term mortality are comparable. Moreover, the timing of tracheostomy (early or late) had comparable rates of sternal wound infection and short-term mortality.

OBJECTIVES: Postoperative atrial fibrillation (PAF) occurs commonly following pulmonary resection. Our aims were to quantify the incidence and severity of PAF using the Thoracic Morbidity & Mortality classification system, and identify risk factors for PAF. METHODS: All consecutive patients undergoing pulmonary resection at a single centre (January 2008 - April 2010) were enrolled. PAF was defined as postoperative, electrocardiographically documented and requiring initiation of pharmacological therapy. Univariate and multivariate analyses of risk factors associated with the development of PAF were conducted. RESULTS: The incidence of PAF was 11.8% (n = 43) of 363 pulmonary resections (open: n = 173; 47.7%; video-assisted: n = 177; 48.8%; converted: n = 13; 3.6%): sublobar (n = 93; 25.6%), lobectomy (n = 237; 65.3%), bilobectomy (n = 7; 1.9%) and pneumonectomy (n =2 4; 6.6%). Twenty-eight cases (65.1%) were uncomplicated/transient, and 15 cases (34.9%) were complicated/persistent PAF, defined as lasting for >7 days (40.0%), requiring cardioversion (13.3%), vasopressors (33.3%), in-hospital use of anticoagulants (46.7%) and/or anticoagulants on discharge (26.7%). Patients with PAF had increased mean lengths of hospital stay (10.5 days vs 6.9 days; P = 0.04). Peak onset of PAF occurred 2.5 (standard deviation (SD) ± 1.3) days after pulmonary resection, lasting for 1.8 ± 2.8 (mean, ±SD) days. Multivariate analysis identified (relative risk; 95% confidence interval): age ≥70 years (2.3; 1.1–5.1), history of angioplasty/stents/angina (4.0; 1.4–11.3), thoracotomy (3.6; 1.4–9.3), conversion to open thoracotomy (16.5; 2.2–124.0) and extent of surgery/stage (7.1; 1.0–49.4) as predictors of PAF. CONCLUSIONS: While the majority of PAF is uncomplicated and transient, one-third of cases lead to persistence or major intervention. Age, coronary artery disease and extent of surgery/stage increase the risk of PAF following pulmonary resection. Identifying patients with elevated risk may lead to targeted prophylaxis to reduce the incidence of PAF.

Background . It is unclear whether follow-up by a thoracic surgeon after lung cancer resection alters survival. Methods . The charts of 245 early stage (≤ IIB) non–small cell lung cancer patients, diagnosed between 1988 and 1995, were reviewed. Follow-up data were complete to January 1, 1997, in 96.3% (236 of 245) of cases. Results . Ninety of the 111 recurrences were detected before discharge from the thoracic clinic. Despite clinic follow-up, 66.7% (60 of 90) were identified by the family physician, and only 28.9% (26 of 90) by the surgeon. The remaining 4.4% (4 of 90) were detected by other physicians. Ninety-six percent (25 of 26) surgeon-detected recurrences had suspicious clinical or chest radiographic findings, compared with 92% for family physician–detected recurrences (55 of 60; not significant). The cost per recurrence detected by surgeons was Can $4,367. A 75% cost savings could ensure if patients were followed up by their family physician. There was no 5-year survival benefit for patients whose recurrence was detected by the surgeon. Conclusions . Long-term follow-up after limited-stage non–small cell lung cancer resection could possibly be performed by a family physician alone without compromising overall survival, and with significant cost savings.

Monitoring surgical outcomes is critical to quality improvement; however, different data-collection methodologies can provide divergent evaluations of surgical outcomes. We compared postoperative adverse event reporting on the same patients using 2 classification systems: the retrospectively recorded American College of Surgeons (ACS) NSQIP and the prospectively collected Thoracic Morbidity and Mortality (TMM) system.Using the TMM system, complications and deaths were documented daily by fellows and reviewed weekly by staff for all thoracic surgical cases conducted at our institution (April 1, 2010 to December 31, 2011). The ACS NSQIP recording was performed 30 to 120 days after index surgery by trained surgical clinical reviewers on a systemic sampling of major cases during the same time period. Univariate analyses of the data were performed.During the study period, 1,788 thoracic procedures were performed (1,091 were designated "major," as per ACS NSQIP inclusion criteria). The ACS NSQIP evaluated 182 of these procedures, representing 21.1% and 16.7% of patients and procedures, respectively. Mortality rates were 1.4% in TMM vs 2.2% in ACS NSQIP (p = 0.42). Total patients and procedures with complications reported were 24.4% and 31.1% by TMM vs 20.2% and 39.0% by ACS NSQIP (p = 0.23 and 0.03), respectively. Rates of reported cardiac complications were higher in TMM vs ACS NSQIP (5.8% vs 1.1%; p = 0.01), and wound complications were lower (2.5% vs 6.0%; p = 0.01).Although overall rates were similar, significant differences in collection, definitions, and classification of postoperative adverse events were observed when comparing TMM and ACS NSQIP. Although both systems offer complementary value, harmonization of definitions and severity classification would enhance quality-improvement programs.

Background Surgical resection for tissue diagnosis of lung nodules exposes patients to unnecessary risks and consumes health care resources for questionable benefit. We describe the impact of routine percutaneous lung biopsy on the management of suspicious lung nodules. Methods A retrospective review of consecutive patients referred to a regional cancer assessment center for evaluation of suspected primary or metastatic lung cancer was performed. Results From 2008 to 2010, 901 patients (male to female ratio, 0.97:1 [443 to 458]; mean age, 69.4 ± 0.3 years) underwent 1,016 percutaneous lung biopsy (fluoroscopy, 77%; computed tomography–guided, 20%). Diagnoses were non–small cell lung cancer (602 of 901; 66.8%), other malignancy (159 of 901; 17.6%), indeterminate (61 of 901; 6.8%), benign (47 of 901; 5.2%), or nondiagnostic (32 of 901; 3.6%). Of these, 393 (43.6%) were surgical candidates. Operation was avoided in 16.0% (63 of 393; benign, 36; indeterminate, 13; nondiagnostic, 14). Computed tomography follow-up in 82.5% (52 of 63) showed no change or resolution at 14.0 ± 1 months. Only 2.7% (9 of 330) underwent resection of a pathologically benign nodule. Diagnostic yield of percutaneous lung biopsy was 82.7%. Sensitivity, specificity, and positive and negative predictive values, respectively, were 100% (95% confidence interval, 98 to 100), 75% (95% confidence interval, 22 to 99), 99.7% (95% confidence interval, 98 to 100), and 100% (95% confidence interval, 31 to 100). The mean operating room time saved with this strategy was 165 ± 13.2 hours. The total cost of performing routine percutaneous biopsy ($395,500) was 44.5% of the cost of upfront wedge resection for tissue diagnosis ($888,300). Conclusions In surgical candidates, routine needle biopsy of suspicious lung nodules may lead to decreased costs, more efficient use of limited operating room resources, and a low probability of resecting pathologically benign lesions.

Neoadjuvant chemoradiation followed by surgery (NeoCRT) has been advocated as standard therapy for resectable esophageal cancer. Our objective was to compare oncologic outcomes between NeoCRT and upfront surgical resection (SURG).We conducted a single-institution, retrospective review of all potentially resectable esophageal cancer patients treated with NeoCRT or SURG.From 2003 to 2010, 151 patients had NeoCRT (n = 48; 31.8%) or SURG (n = 103; 68.1%). Histology was mostly adenocarcinoma (77.5%) or squamous carcinoma (19.2%). Mean radiation dose was 44 ± 0.1 Gy, and 80.8% received platinum-based doublet chemotherapy. There were more women in the SURG group (23.3% vs 4.2%; p0.01) and more cardiovascular comorbidity in the NeoCRT group (39.6% vs 21.4%; p = 0.027). There was no difference in age, histology, R0 resection rate, and treatment-related mortality (NeoCRT = 4.2%; SURG = 3.9%; p = 0.15). Failure to undergo resection after NeoCRT (n = 11; 22.9%) was mainly due to disease progression (n = 6) or treatment-related mortality (n = 4). Resection could not be performed in 4 SURG patients (3.9%; p0.001; unresectable = 2; occult metastases = 2). NeoCRT did not improve median survival (NeoCRT = 29 ± 6; SURG = 26 ± 3 months; p = 0.376) or recurrence-free interval (NeoCRT = 25.8 ± 5; SURG = 19.4 ± 2 months; p = 0.19). Complete pathologic response (n = 8; 21.6%) was not associated with improved survival. If we exclude from analysis NeoCRT patients who did not undergo surgery, survival was significantly improved after NeoCRT (NeoCRT = 41 ± 15; SURG = 24 ± 8 months; p = 0.0082).Patient selection and early assessment of treatment response may be key factors in identifying the best candidates for trimodality therapy.

The aim of this study was to compare our experience between open and video-assisted thoracic surgery (VATS) approaches to the management of thoracic effusions in ventricular assist device (VAD) patients. This was a retrospective review of a prospectively collected database of VAD patients at a single institution. Patients who were operated on for pericardial and/or pleural effusions were included. Primary outcomes included operative mortality and morbidity as well as effusion recurrence. From 1993 to 2009, 360 adult patients underwent VAD placement. Twenty-three patients (11.9%) required operative management of pleural (n = 24), pericardial (n = 13) or both pleural and pericardial (n = 6) effusions [open = 20 (47%); VATS = 23 (53%)]. Drainage with decortication was performed in five patients, with the remaining undergoing drainage alone. Open and VATS patients were similar in age, gender and indication for VAD support. Conversion from VATS to open was necessary in four patients (17%). There was no operative mortality and no difference in perioperative complications between approaches. The open and VATS approaches had similar rates of pleural (open = 63%; VATS = 41%; P = 0.42) and pericardial (open = 31%; VATS = 17%; P = 1) effusion recurrences. In spite of apparent challenges, the VATS approach may be as safe and effective as open surgery for the management of pleural and pericardial effusions in VAD patients in centres with significant minimally invasive thoracic experience.

Objectives Assessing the degree of involvement and participation in thoracic surgical research as well as surgical quality improvement conducted across Canadian institutions is difficult as no common data collection system and no prior studies exist. As a pilot investigation, we designed and conducted a membership survey of the Canadian Association of Thoracic Surgeons (CATS) to evaluate the extent of participation in research and quality improvement processes among thoracic surgeons. Design, Setting, and Participants A 45-item needs assessment survey was mailed to all national members of CATS (n = 86) in August 2009. Questions primarily focused on clinical research programs and research activity, research funding, database use and interest, and other methods of quality monitoring. Results The 49 completed surveys represented a 57.0% response rate and 28 institutions across Canada. Research in basic and clinical science is conducted by 17.0% and 80.9% of the respondents, respectively. The annual budget of research funds is most commonly between $5000 and $50,000. A total of 72.0% (n = 18) of institutions do not have a formal surgery quality assessment program and 92.3% (n = 24) do not participate in a national or international thoracic surgery database. Ten institutions (38.6%) have a local thoracic surgery database for quality monitoring. Other systems of monitoring surgical quality include formal morbidity and mortality rounds (69.2%; n = 8 institutions), formal evaluation of surgical wait times (73.1%; n = 19 institutions), and patient satisfaction surveys (71.4%; n = 10 institutions). Overall, 97.8% of surgeons would be willing to share data on morbidity and mortality with other centers, and 73.1% have a high or very high level of interest in participating in a national thoracic surgery quality database. Conclusions A high level of interest and participation exists in thoracic surgery research. However, more robust quality improvement processes are needed for thoracic surgical oncology services. A national thoracic surgery quality improvement database offers a potential means to improve practice effectiveness, standardize surgical outcomes, and promote thoracic research across Canada.

This study was undertaken to characterize the pharmacokinetics and bioavailability of voriconazole in adult lung transplant patients during the early postoperative period, identify factors significantly associated with various pharmacokinetic parameters, and make recommendations for adequate dosing regimens. Thirteen lung transplant patients received two intravenous infusions (6 mg/kg, twice daily [b.i.d.]) immediately posttransplant followed by oral doses (200 mg, b.i.d.) for prophylaxis. Blood samples (9/interval) were collected during one intravenous and one oral dosing interval from each patient. Voriconazole plasma concentrations were measured by high-pressure liquid chromatography (HPLC). NONMEM was used to develop pharmacokinetic models, evaluate covariate relationships, and perform Monte Carlo simulations. There was a good correlation ( R 2 = 0.98) between the area under the concentration-time curve specific for the dose evaluated (AUC 0-∞ ) and trough concentrations. A two-compartment model adequately described the data. Population estimates of bioavailability, clearance, V c , and V p were 45.9%, 3.45 liters/h, 54.7 liters, and 143 liters. Patients with cystic fibrosis (CF) exhibited a significantly lower bioavailability (23.7%, n = 3) than non-CF patients (63.3%, n = 10). Bioavailability increased with postoperative time and reached steady levels in about 1 week. V p increased with body weight. Bioavailability of voriconazole is substantially lower in lung transplant patients than non-transplant subjects but significantly increases with postoperative time. CF patients exhibit significantly lower bioavailability and exposure of voriconazole and therefore need higher doses. Intravenous administration of voriconazole during the first postoperative day followed by oral doses of 200 mg or 400 mg appeared to be the optimal dosing regimen. However, voriconazole levels should be monitored, and the dose should be individualized based on trough concentrations as a good measure of drug exposure.

Patients diagnosed with Barrett's esophagus and high-grade dysplasia may harbor an intramucosal or early stage invasive esophageal carcinoma. The presence of and associated invasive malignancy exposes the patient to the risk of lymph node metastasis and its devastating effect on survival, regardless of treatment. The authors recommend that patients diagnosed with Barrett's esophagus and highgrade dysplasia be evaluated by an esophageal surgeon, who will be able to confirm the diagnosis and review the surgical options along with their potential benefits and risks. By continuously refining minimally invasive surgical techniques and perioperative care, esophageal resection should remain an acceptable option to patients with this disease.

Rationale: The molecular mechanisms underlying acute exacerbations of idiopathic pulmonary fibrosis (IPF) are poorly understood. We studied the global gene expression signature of acute exacerbations of IPF. Objectives: To understand the gene expression patterns of acute exacerbations of IPF. Methods: RNA was extracted from 23 stable IPF lungs, 8 IPF lungs with acute exacerbation (IPF-AEx), and 15 control lungs and used for hybridization on Agilent gene expression microarrays. Functional analysis of genes was performed with Spotfire and Genomica. Gene validations for MMP1, MMP7, AGER, DEFA1–3, COL1A2, and CCNA2 were performed by real-time quantitative reverse transcription-polymerase chain reaction. Immunohistochemistry and in situ terminal deoxynucleotidyltransferase dUTP nick end-labeling assays were performed on the same tissues used for the microarray. ELISA for α-defensins was performed on plasma from control subjects, patients with stable IPF, and patients with IPF-AEx. Measurements and Main Results: Gene expression patterns in IPF-AEx and IPF samples were similar for the genes that distinguish IPF from control lungs. Five hundred and seventy-nine genes were differentially expressed (false discovery rate < 5%) between stable IPF and IPF-AEx. Functional analysis of these genes did not indicate any evidence of an infectious or overwhelming inflammatory etiology. CCNA2 and α-defensins were among the most up-regulated genes. CCNA2 and α-defensin protein levels were also higher and localized to the epithelium of IPF-AEx, where widespread apoptosis was also detected. α-Defensin protein levels were increased in the peripheral blood of patients with IPF-AEx. Conclusions: Our results indicate that IPF-AEx is characterized by enhanced epithelial injury and proliferation, as reflected by increases in CCNA2 and α-defensins and apoptosis of epithelium. The concomitant increase in α-defensins in the peripheral blood and lungs may suggest their use as biomarkers for this disorder.

Background Short-term outcomes of laparoscopic Heller myotomy (LHM) for achalasia have been excellent, although the long-term durability of this operation remains to be established. The aim of this study was to evaluate the long-term outcomes of LHM. Methods A single-institution review of patients undergoing LHM between 1992 and 2003 with ≥5 years follow-up. Failure was defined as symptom recurrence requiring reoperation. Univariate and multiple regression analysis were performed to identify preoperative variables predictive of long-term success. Results A total of 46 patients underwent LHM with Toupet (n = 42) or Dor (n = 4) fundoplication. At a mean follow-up of 6.4 years, 37 (80%) patients remained free from failure. Mean time to symptom recurrence in those failing LHM was 21.3 months (range, 0.5–77). Causes of failure included nonfunctioning end-stage esophagus (n = 4), fibrotic narrowing at the gastroesophageal junction (n = 4), and tight wrap (n = 1). Univariate analysis identified high preoperative lower esophageal sphincter pressure (LESP), no prior therapy, short duration of symptoms, and absence of sigmoidal esophagus as predictors of long-term success (P ≤ .044 each). High LESP remained the only predictor of long-term durability in multiple regression analysis (P = .043). Reoperations included redo myotomy (n = 2), esophagectomy (n = 6), or both (n = 1). At final follow-up, 44 (96%) patients reported significant symptom improvement compared with pre-LHM severity. Conclusion LHM is associated with an 80% long-term success rate. Successful LHM may be predicted by high LESP, no prior therapy, short symptom duration, or absence of sigmoidal esophagus. In this series, failures of LHM underwent reoperation (redo myotomy or esophagectomy) with good results.

Five days following bilateral thoracoscopic lung volume reduction surgery for emphysema, a 63-year-old man underwent reoperation for closure of a massive bronchopleural fistula. It was discovered intraoperatively that the fistula was located distant from prior staple lines or resection sites from his surgery. This case is an example of what may be a unique pathophysiologic mechanism of bronchopleural fistula formation--a 'stress rupture' of the lung parenchyma following lung volume reduction surgery.

Abnormal body mass index has been targeted as a predictor of complications after major surgery. The aim of this study was to review the impact of obesity on perioperative outcomes after minimally invasive esophagectomy.This study was a single-institution retrospective review of patients undergoing minimally invasive esophagectomy for high-grade dysplasia or cancer of the esophagus between 1999 and 2004. A body mass index of 30 or greater was considered obese. Patients with a body mass index less than 18.5 were excluded because of the potentially adverse effects of malnutrition on outcomes.A total of 282 eligible patients were identified. There were 84 obese and 198 nonobese patients (mean body mass index = 34.5 versus 25.5; p0.0001). Preoperative demographics, comorbidities, and cancer status were similar, except for a higher prevalence of diabetes (p = 0.002), lower prevalence of peripheral vascular disease (p = 0.045), and lower prevalence of stage III disease in the obese group (p = 0.044). Operative time was significantly longer in obese patients (375 versus 301 minutes; p = 0.0001), and estimated blood loss was similar (433 versus 377 mL, obese versus nonobese, respectively). There were 5 (1.8%) overall 30-day perioperative mortalities, with no differences between the groups. Overall major (obese, 23 [27.5%] versus nonobese, 68 [34.3%]) and minor (obese, 23 [27.5%] versus nonobese, 65 [32.8%]) complication rates were also similar. Furthermore, there were no significant differences in any individual complications. There was no difference in median intensive care unit stay (obese, 1 day versus nonobese, 2 days) or overall hospital stay (obese, 7 days versus nonobese, 8 days).Obesity was associated with longer operative times. Our review suggests that obesity is not a risk factor for mortality, postoperative complications, or length of hospitalization after minimally invasive esophagectomy.

Background The optimal management of benign tracheal stricture remains surgical resection. Resection is not always an option because of the challenges posed by anastomotic tension and a tenuous blood supply. Regenerative medicine approaches, such as extracellular matrix (ECM) scaffold technology, may alleviate some of the limitations to tracheal replacement. ECM scaffolds facilitate site-specific tissue remodeling when used to reconstruct a variety of soft-tissue structures. Methods A 1-cm wide × 2-cm-long defect was created in the ventral trachea of 15 dogs and repaired with one of three acellular biologic scaffolds: urinary bladder matrix (UBM), UBM crosslinked with carbodiimide (UBMC), and decellularized tracheal matrix (DTM). The grafts were evaluated periodically using bronchoscopy and by macroscopic and microscopic morphologic examination at either 2 months or 6 months. Results The UBM, UBMC, and DTM groups showed no evidence of stenosis or tracheomalacia. The UBM, UBMC, and DTM groups all showed deposition of organized collagenous tissue at the site of scaffold placement and an intact epithelial layer. Scattered areas of mucociliary differentiation were present at the edges of the graft site. There was no evidence cartilage observed within the remodeled tissue at 6 months. Conclusions ECM scaffolds promote healing of significantly sized tracheal defects without stricture and with some, but not all, of the necessary structures required for tracheal reconstruction, including complete coverage with ciliated epithelium and dense organized collagenous tissue.

Background Surgical resection is the standard of care for patients with resectable non-small cell lung cancer or selected patients with pulmonary metastases. Stereotactic radiosurgery may offer an alternative option for high-risk patients who are not surgical candidates. We report our initial experience with stereotactic radiosurgery in the treatment of lung neoplasm in 100 consecutive patients. Methods Patients who were medically inoperable were offered stereotactic radiosurgery. Thoracic surgeons evaluated all patients, placed fiducials, and performed treatment planning in collaboration with radiation oncologists. Initially, a median dose of 20 Gy prescribed to the 80% isodose line was administered in a single fraction, and this was subsequently increased to a total of 60 Gy in three fractions. The primary end point evaluated was overall survival. Results We treated 100 patients (median age, 70 years; 51 men, 49 women) with stereotactic radiosurgery: 46 (46%) with primary lung neoplasm, 35 (35%) with recurrent cancer, and 19 (19%) with pulmonary metastases. The median follow-up was 20 months. The median overall survival was 24 months. Local recurrence occurred in 25 patients. The probability of 2-year overall survival was 50% for the entire group, 44% for primary lung cancer, 41% for recurrent cancer, and 84% for metastatic cancer. Conclusions Our initial experience indicates that stereotactic radiosurgery has reasonable results in these high-risk patients. Resection continues to remain the standard treatment; however, stereotactic radiosurgery may offer an alternative in high-risk patients. Further prospective studies with different dose schema are needed to evaluate the efficacy of stereotactic radiosurgery.

RFA and SRS have been demonstrated to be safe with reasonable efficacy in the treatment of small lung tumors. It is unclear which option is the most effective in the treatment of NSCLC, with both RFA and SRS demonstrating similar early response and progression rates. RFA can be performed in one treatment session, whereas it now seems that SRS is more effective if larger doses of radiation over two to three fractions are performed. RFA is not recommended for centrally based tumors. There are also some tumors (eg, small apical tumors, posteriorly positioned tumors close to the diaphragm, and tumors close to the scapula) where it may be difficult percutaneously to position an active electrode. Such patients are more optimally treated with SRS. In certain circumstances, a combined approach may be beneficial (RFA and SRS). At this point in time, MWA is the least well developed modality. Although treatment times and heat-sink effect may be less compared with RFA, larger trials are needed to understand better the impact of this factor on effectiveness and safety. The heat-sink effect may be protective, minimizing the necrosis of large blood vessels and the risk of subsequent fatal hemoptysis. Future studies need to address long-term outcomes using standardized assessments of treatment response between centers. Comparisons between different RFA systems and ablation modalities need to be undertaken to delineate the optimal use of these strategies in the treatment of early stage lung cancer. Until long-term data with these ablative techniques become available, surgical resection should be performed when clinically possible.

The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients. We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25–83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure. The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant. MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients.

Background The primary objective of this study was to review our experience with minimally-invasive esophagomyotomy as primary therapy for achalasia, and to identify those clinical variables most predictive of myotomy failure. Methods We reviewed our experience with all patients who underwent minimally-invasive Heller myotomy from 1992 to 2005. Outcome variables analyzed included perioperative morbidity and mortality, symptomatic improvement, and requirement for postoperative interventions. Multivariate analysis was performed to identify clinical variables predictive of myotomy failure. Results A total of 200 consecutive patients (104 men and 96 women) underwent minimally-invasive laparoscopic (n = 194) or thoracoscopic (n = 6) Heller myotomy with partial fundoplication. Mean follow-up was 31.6 months. Median hospital stay was 2 days, with no operative mortality. There were 119 patients (59.5%) who had undergone prior endoscopic treatment (endoscopic dilation or botulinum toxin injection). An increased failure rate was noted in patients with prior endoscopic therapies (16.8% versus 3.7% with no prior treatment, p = 0.003). Multivariate analysis also revealed that longer duration of symptoms, sigmoidal esophageal changes, and low preoperative lower esophageal sphincter pressures impact adversely on the success of myotomy. Conclusions There was an increase in treatment failures among patients undergoing preoperative endoscopic treatment. Other factors associated with failure during long-term follow-up include longer duration of symptoms, sigmoidal esophagus, and low baseline lower esophageal sphincter pressure. Although endoscopic modalities remain an important component of the armamentarium in the treatment of patients with achalasia, consideration should be given to minimally-invasive Heller myotomy as primary therapy for this condition.

Rationale and Objectives This study was designed to develop an automated method for estimating lung volume removed during lung volume reduction surgery (LVRS) using computed tomography (CT). Materials and Methods The CT examinations of six patients who underwent bilateral LVRS were analyzed in this study. The resected lung tissue (right and left) was weighed during pathologic examination. An automated computer scheme was developed to estimate the lung volume removed using the CT voxel values and lung specimen weight. The computed fraction of lung volume removed was evaluated across a range of simulated surgical planes (ie, other than parallel to the CT image plane) and CT reconstruction kernels, and it was compared with the surgeons’ postsurgical estimates. Results The computed fraction of the lung volume removed during LVRS was linearly correlated with the resected lung tissue weight (Pearson correlation = 0.697, P = .012). The computed fraction of lung volume removed ranged from 12.9% to 51.7% of the total lung volume. The surgeons’ postsurgical estimates of lung volume removed ranged from 30% to 33%. The percent difference between the surgeons’ estimates and the computed lung volume removed as a percentage of the surgeons’ estimates ranged from −72.3% to 57.0% with mean absolute difference of 29.7% (±20.7). Conclusion The preliminary findings of this study suggest that the proposed quantitative model should provide an objective measure of lung volume removed during LVRS that may be used to investigate the relationship between lung volume removed and outcome.

Gastroesophageal reflux disease (GERD)-induced pulmonary symptoms (PS) can be difficult to control. The effectiveness of laparoscopic fundoplication (LF) in controlling PS among patients with medically recalcitrant GERD is poorly documented. We evaluated our results in controlling important PS in patients with GERD undergoing LF.Seventy-four patients (28 men, 46 women) were identified with clinically important PS from a prospective cohort of 155 patients undergoing elective LF for recalcitrant GERD. Median age was 52.5 years (range, 29-84 years). Sixty-seven (91%) patients were taking proton pump inhibitors at the time of operation. Quality of life by using the SF36 physical (PCS) and mental (MCS) component summary scores (normal, 50) and heartburn severity by using the health-related quality of life (HRQOL) (best score, 0; worst score, 45) were measured.All 74 patients with PS survived operation, and minor morbidity occurred in 5 (7%) patients. Median hospital stay was 2 days (range, 1-6 days), and return to normal activity was seen at 2.2 weeks (range, 1-8 weeks). Median follow-up was 12 months. PS were improved significantly (P.01) for hoarseness (62% to 17.6%), bronchospasm (60% to 9.5%), and aspiration (22% to 1.4%). Before LF, 11 (14.9%) patients required bronchodilators or oral steroids. Postoperatively such therapy was required in only 3 (4.2%) patients (P = .019), with no patient requiring oral steroids. Patients with poorer control of their GERD on the basis of high HRQOL scores had significantly more PS after operation.A significant number of patients with medically recalcitrant GERD (46% from our prospective database) have important PS. LF can improve PS, decrease requirement for pulmonary medications, as well as improve typical reflux symptoms and quality of life.

Detection of clinically occult lung neoplasms may represent an opportunity for early curative intervention. Fluorescent bronchoscopy is a sensitive technique for detecting early endobronchial tumors that may be combined with CT scanning as part of a comprehensive lung cancer screening program. Identification and longitudinal follow-up of dysplastic endobronchial changes with fluorescent bronchoscopy should facilitate studies of chemoprevention and further knowledge regarding the natural history of these lesions. Analysis of bronchial epithelium with novel techniques such as genomic hybridization and gene expression arrays might provide even better predictors of progression of dysplastic endobronchial lesions.

The University of Pittsburgh lung transplantation program began in 1982 and through 2002 we have performed 576 lung and 101 heart-lung transplants. One-, 3- and 5-year survival rates over the past decade have been 77%, 62% and 55%, respectively, comparing favorably to ISHLT registry outcomes of 73%, 57% and 46%. We continue to utilize a very thorough evaluation process but have been flexible and aggressive with potential recipients with regard to age, coronary artery disease and disease state (eg., scleroderma). Despite worldwide progress in the field of lung transplantation, many difficulties remain. The limited number of lungs deemed acceptable for transplantation continues to hinder application to a greater number of patients. Our efforts in this regard have focused on cooperation with our OPO in education and detailed donor management protocols. Chronic rejection also remains a major difficulty frequently leading to death. Recent work utilizing aerosol cyclosporine in patients with established chronic rejection suggests that this therapy may prolong life. We are also hopeful that recently initiated therapies utilizing T-cell induction strategies may contribute to further improvement in outcomes.

We read with great interest the recent original research article by Bjerregaard et al. [1]. By reporting pertinent 30-day outcomes for fasttrack chest tube removal following video-assisted thoracoscopic (VATS) lobectomy with

Background: Resident feedback can lead to an improvement in teaching performance. Compliance with our previous rotation evaluation system has been poor. Methods: Rotation evaluation forms were integrated to the departmental World-Wide-Web site. Anonymously completed evaluations are automatically sent to an appointed surgery professor via electronic mail (e-mail). They are then collated and transmitted to program directors. Results: Ninety-two percent (24 of 26) of our surgical residents have an e-mailaccount. During the 2-month trial, 18 residents completed 48 evaluations. This represents a 75% (18 of 24) compliance rate among residents with e-mail capabilities. The response rate was 82% (9 of 11) for core residents, 64% (7 of 11) for third- and fourth-year residents, and 50% (2 of 4) for chiefs. A second 2-month trial yielded a 75% (18 of 24) response rate and 43 evaluations. Conclusions: The World-Wide-Web is a user-friendly medium suitable to obtain valuable feedback on the quality of residency training. Compliance was improved using this new system.