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BACKGROUND Airway release (AR) maneuvers performed during airway resection to reduce anastomotic tension have not been thoroughly studied. METHODS This study retrospectively analyzed consecutive resections for postintubation stenosis (PITS) and primary tracheal neoplasms (PTNs) at Massachusetts General Hospital (Boston, MA). Anastomotic complications were defined as stenosis, separation, necrosis, granulation tissue, and air leak. Logistic regression modeling was used to identify factors associated with AR and adverse outcome. RESULTS From 1993 to 2019, 545 patients with PITS (375; 68.8%) and PTNs (170; 31.2%) underwent laryngotracheal, tracheal, or carinal (resections and reconstructions; 5.7% (31 of 545) were reoperations. AR was performed in 11% (60 of 545): in 3.8% of laryngotracheal resections (6 of 157; all laryngeal), in 9.8% of tracheal resections (34 of 347; laryngeal, 12, and hilar, 22), and in 49% of carinal resections (20 of 41; laryngeal, 1, and hilar, 19). Mean resected length was 3.5 cm (range, 1to- 6.3 cm) with AR and 3.0 cm (range, 0.8 to 6.5 cm) without AR (P < .01). Operative mortality was 0.7% (4 of 545); all 4 anastomoses were intact until death. Anastomotic complications were present in 5% of patients who underwent AR (3 of 60) and in 9.3% (45 of 485) of patients who did not. AR was associated with resection length of 4 cm or longer (odds ratio [OR], 6.15; 95% confidence interval [CI], 1.37 to 27.65), PTNs (OR, 7.81; 95% CI, 3.31 to 18.40), younger age (OR, 0.96; 95% CI, 0.94 to 0.98), and lung resection (OR, 6.09; 95% CI, 1.33 to 27.90). Anastomotic complications in patients with tracheal anastomoses were associated with preexisting tracheostomy (OR, 2.68; 95% CI, 1.50 to 4.80), but not release. CONCLUSIONS Tracheal reconstruction succeeds, even when anastomotic tension requires AR. Because intraoperative assessment may underestimate tension, lowering the threshold for AR seems prudent, particularly in patients with diabetes.

We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population.Cohort study using the California Public Discharge Data file (1995-2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis.Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14-1.36), Asian race (HR 1.24, CI 1.13-1.37), and tube thoracostomy (HR 1.2, CI 1.15-1.31). Mechancial pleurodesis (HR 0.37 CI 0.31-0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58-0.86) in reducing recurrence risk.The risk of recurrent pneumothorax is greatest in patients age35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence.

Given the association between lymphadenectomy and survival after esophagectomy, and the ongoing development of effective adjuvant protocols for identified residual disease, we determined factors contributing to lymph node yield and effects on postoperative morbidity following esophagectomy by thoracic surgeons. Using the Society of Thoracic Surgeons General Thoracic Surgery Database, all patients who underwent esophagectomy for primary esophageal cancer with gastric conduit reconstruction from 2012 to 2016 were identified. Patient demographics, technical factors, and tumor characteristics associated with lymph node yield were determined using a multivariable multilevel mixed-effects regression model. Associations between lymph node yield and perioperative morbidity and mortality were similarly assessed. A total of 8480 patients were included. The median number of nodes harvested was 16 [Interquartile Range 11–22]. Factors associated with fewer nodes included female gender (b=−0.53, P=0.032), body mass index

Air leaks and residual airspaces following lung resection are common problems in thoracic surgery. Prolonged air leaks frequently necessitate extended hospitalization. This is true whether the surgery was done in an open fashion or with video-/robot-assisted thoracic surgery. In this review, the authors present common risk factors that predispose to prolonged air leaks and discuss the management options for air leaks by focusing on intraoperative maneuvers, postoperative considerations, and options for difficult-to-manage air leaks and spaces. They also discuss options to prevent such spaces and present management approaches to take care of patients with these challenging problems.

Despite an ever-diversifying United States population, women and underrepresented minorities lack proportionate membership in the cardiothoracic surgery workforce. Many Society of Thoracic Surgeons (STS) members view achieving a diverse cardiothoracic surgery workforce as important. To address the needs of our specialty to better reflect and understand (cultural competence) our evolving communities, the STS created the Workforce on Diversity and Inclusion. The Workforce's mission is to cultivate an environment of inclusion and diversity within the STS as well as the cardiothoracic surgical specialty. This report will discuss the background for the creation of the Workforce on Diversity and Inclusion, describe the "return on investment" in diversity, the current state of diversity in surgery, illustrate STS members' views on the importance of a diverse specialty, and present current and future activities of the Workforce on Diversity and Inclusion.

Resident education in the operating room and surgical resident autonomy represent two enormous challenges within cardiothoracic (CT) training programs. The goal of surgical educators and CT trainees is to ensure the graduating resident's ability to safely operate independently at the completion of training. The field has come a long way from the notion of see one, do one, teach one, which was once the norm. Cardiothoracic surgery continues to become more specialized and the patients more complex with greater scrutiny of outcomes. There are many challenges that are faced in contemporary CT training to make intraoperative teaching harder than ever.

The clinical impact of a positive radial margin after esophagectomy for cancer has not been clearly identified. The goal of this study was to identify risk factors for a positive radial margin and determine the impact on recurrence and survival. Retrospective review of 196 patients with pathological T3 N0-3 esophageal adenocarcinoma undergoing esophagectomy between 2002 and 2017. Mortality data was extracted from Electronic Medical Records and Social Security Death Index. Mean age was 63.7 ± 11.4 years, and there were 166 (84.7%) men. Neoadjuvant therapy was given in 141(71.9%) patients. We identified 29(14.8%) patients with a positive radial margin. Factors significantly associated with a positive radial margin include not receiving neoadjuvant therapy and presence of lymphatic, vascular, or perineural invasion. Overall, there were 94(48%) recurrences during a mean follow-up of 24.7 months. Involvement of the radial margin was not significantly associated with recurrence-free survival (HR 1.24, CI 95% 0.73–2.12, p = 0.425). Overall survival for the entire cohort was 41.6% and 28.9% at 3 and 5 years, respectively. Involvement of the radial margin did not have a significant impact on overall survival (HR 1.23, CI 95% 0.68–2.22, p = 0.493). The likelihood of encountering a positive margin is associated with lack of neoadjuvant treatment and the presence of lymphatic, vascular, or perineural invasion in the esophagectomy specimen. An involved radial margin after esophagectomy for locally advanced cancer was not associated with tumor recurrence or overall survival in our cohort, and other factors such as lymph node involvement are stronger in determining outcome.

The purpose of this study was to quantify the cost impact of complications of esophagectomy and identify opportunities for reducing costs while optimizing outcomes. Patients undergoing esophagectomy at a single institution between 2002 and 2017 were included. Complications were tabulated from clinical data. Direct hospital costs were determined for all encounters between the day of surgery and postoperative day 90. Risk factors were assessed using logistic regression. The relative incremental cost of complications was assessed using multivariable linear regression. A total of 761 patients were included in this study. 428 patients (56%) experienced at least 1 complication. Factors associated with increased likelihood of complications included age (P0.001), female sex (P = 0.005), pack-years (P = 0.006), cerebrovascular disease (P = 0.021), and diabetes (P = 0.052). The most common complications were atrial arrhythmia (18%), transfusion (15%), and atelectasis requiring bronchoscopy (8%). The complications incurring the greatest incremental cost per event were anastomotic complications requiring surgical treatment (200%, P0.001) or those treated nonoperatively (96%, P0.001), and renal failure (178%, P0.001). Pneumonia increased costs by 40% (P0.001) and other major pulmonary complications increased costs by 75% (P0.001). Though the cost of complications was unaffected by surgical approach (minimally invasive esophagectomy vs open), MIE was associated with decreased cost vis-à-vis a lower complication rate (41% vs 60%, P0.001). Complications accounted for 28% of the aggregate 90-day direct hospital cost for all patients. Pulmonary complications accounted for 35% of all complication-attributable costs, while anastomotic complications accounted for 17%. Anastomotic and pulmonary complications after esophagectomy with gastric conduit reconstruction represent high-yield targets for cost reduction and quality improvement.

Background Post-esophagectomy tracheo-bronchial-esophageal fistula (PETEF) most often develops after anastomotic disruption or gastric conduit necrosis. Ideal surgical management and outcomes for this complication are uncertain. Methods A retrospective review of 11 patients undergoing surgical repair of PETEF was performed. Results The median time between esophagectomy and surgical repair of PETEF was 61 days (range, 7 days to 28 years). Anastomotic leak or gastric conduit necrosis was responsible for PETEF in 6 patients (54.5%), whereas other causes were erosion of a tracheal appliance (n = 2), gastric conduit staple line erosion (n = 1), anastomotic stricture dilation (n = 1), and recurrent esophageal cancer (n = 1). Membranous airway defects were repaired primarily and buttressed with muscle or omental flaps in 8 patients (72.7%), whereas two (18.2%) were repaired with bio-prosthetic patches and one (9.1%) was repaired with a sleeve resection of the bronchus. Anastomotic and neo-esophageal conduit defects were repaired primarily in 3 patients (27.3%), whereas 7 patients (63.6%) underwent conduit take-down and esophageal or pharyngeal diversion, and 1 patient (9.1%) underwent simultaneous fistula repair and colon interposition. Two patients (18.2%) had recurrent fistulas, with 1 patient dying after second fistula closure and the other was discharged with no further attempt at repair. Three patients (27.3%) died postoperatively. Only 3 patients (27.3%) resumed an oral diet after fistula repair. Conclusions Surgical treatment is effective for most patients undergoing operative repair of PETEF, notwithstanding a considerable risk of postoperative morbidity and death. Although fistula repair is life saving and prevents further respiratory deterioration, return to oral alimentation is not ensured.

Decellularized native extracellular matrix (ECM) biomaterials are widely used in tissue engineering and have reached clinical application as biomesh implants. To enhance their regenerative properties and postimplantation performance, ECM biomaterials could be functionalized via immobilization of bioactive molecules. To facilitate ECM functionalization, we developed a metabolic glycan labeling approach using physiologic pathways to covalently incorporate click-reactive azide ligands into the native ECM of a wide variety of rodent tissues and organs in vivo, and into the ECM of isolated rodent and porcine lungs cultured ex vivo. The incorporated azides within the ECM were preserved after decellularization and served as chemoselective ligands for subsequent bioconjugation via click chemistry. As proof of principle, we generated alkyne-modified heparin, immobilized it onto azide-incorporated acellular lungs, and demonstrated its bioactivity by Antithrombin III immobilization and Factor Xa inhibition. The herein reported metabolic glycan labeling approach represents a novel platform technology for manufacturing click-reactive native ECM biomaterials, thereby enabling efficient and chemoselective functionalization of these materials to facilitate tissue regeneration and repair.

OBJECTIVES Gastric emptying delay after oesophagectomy may occur in conduits exposed to pleural forces of respiration or anatomic obstruction. Remedial operations addressing both causes are rarely reported. The study aim was to categorize severe gastric conduit obstruction (GCO) and report the outcome of surgical revision. METHODS A single-institution, retrospective study of gastric conduit revision following oesophagectomy for oesophageal cancer investigated incidence, risk factors and categories of conduit obstruction. Evaluation consisted of contrast studies, computed tomogram and endoscopy. Interventions were categorized according to obstructive cause and included pyloroplasty, hiatal hernia reduction and thoraco-abdominal conduit repositioning. RESULTS Among 1246 oesophagectomies over a 17-year period, 14 patients (1.1%) required post-oesophagectomy relief of GCO. Two additional patients presented after oesophagectomy elsewhere. Before oesophagectomy, 18.8% (3/16) and 62.5% (10/16) of patients were on chronic opioid and psychotropic medications, respectively. Distinct anatomic features separated obstruction into 3 categories: pyloric in 31% (5/16), extrinsic in 12.5% (2/16) and combined in 56.3% (9/16). Operative revision led to complete symptom resolution in 50% (8/16) of patients and symptom improvement in 43.8% (7/16) of patients. One patient (1/16, 6.25%) in the combined obstruction group did not improve with surgical revision. CONCLUSIONS GCO after oesophagectomy rarely requires surgical revision. Potential association with medications affecting oesophageal and gastric motility requires further investigation. Classification of obstruction identifies a patient subset with lower success after surgical revision.

Summary Background Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. Methods A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. Results Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02–3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31–17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39–4.43], P = 0.046) and sepsis (OR 3.26 [1.44–7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. Conclusions Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.

Indications for exploring the mediastinum in the setting of thyroid and parathyroid disease include benign substernal goiter, thyroid malignancy, metastatic lymph nodes arising from thyroid malignancy, and mediastinal parathyroid adenoma. Although these mediastinal pathologies can often be resected through a transcervical approach, a thoracic approach to the mediastinum may be required for complete exposure and resection depending on the lesion’s size, location, and relationship to adjacent structures. These thoracic approaches can include full sternotomy, partial sternotomy, trapdoor incision, and thoracotomy as well as minimally invasive approaches such as mediastinoscopy, thoracoscopy, and robot-assisted thoracoscopic surgery. In cases where a thoracic approach may be required, preoperative consultation and intraoperative collaboration with a cardiothoracic surgeon can facilitate an optimal approach for resection of these intrathoracic mediastinal pathologies.

Approximately 10% to 15% of patients with solitary fibrous tumors of the pleura (SFTP) have recurrence after resection. Many are not candidates for reresection and lack effective treatments. We explored the expression of programmed death ligand 1 (PD-L1) as a biomarker for candidacy for treatment with immune checkpoint inhibitors.We reviewed the medical records of 52 patients with primary SFTP and 5 with recurrent SFTP. We performed immunohistochemistry on tumor tissue to determine the expression of PD-L1 and infiltration by cluster of differentiation 8 (CD8)-positive immune cells.Any PD-L1 expression was observed in 11 primary SFTP (21.2%). Overall, PD-L1 expression level was less than 1% in 10 patients (19.2%) and greater than 1% in 1 (1.9%). Tumor infiltration by CD8-positive immune cells was absent or rare in 13 patients (25%), less than 5% in 31 (59.6%), and 5% to 25% in 8 (15.4%). There were no associations between PD-L1 expression or immune cell infiltrates and known risk factors for recurrence or a prognostic risk score classification. Time to recurrence was strongly associated with the risk score classification (P.001), but it was not associated with PD-L1 expression (P = .296) or immune cell infiltrates (P = .619). In recurrent SFTP, PD-L1 was expressed in 4 of 10 tumors (40%; all1% expression). There was no correlation in PD-L1 expression between primary and recurrent SFTP samples.A small subset of SFTP express PD-L1 at low levels (1%) but exhibit colocalization of CD8-positive immune cells suggesting an inducible expression mechanism. The role of PD-L1 merits exploration in the clinical setting in patients with advanced SFTP when alternative treatments or clinical trials are considered.

OBJECTIVES Idiopathic laryngotracheal stenosis (ILTS) is an uncommon problem arising mostly in women. In some, it arises during or is exacerbated by pregnancy. Experience with management of patients with this rare association is limited. This study seeks to evaluate the management of patients with pregnancy-associated ILTS and compare outcomes to cases not associated with pregnancy. METHODS Retrospective review of 15 patients undergoing surgical treatment of pregnancy-associated ILTS from 1971 to 2013. Variables of interest and airway outcomes were compared to patients with non-pregnancy-associated ILTS. RESULTS Pregnancy-associated ILTS was observed in 15/263 (5.7%) patients. Symptoms developed during their first pregnancy. When compared to non-pregnancy patients, these patients were younger (37 vs 47 years; P = 0.0003), had more prior tracheostomies (26.7% vs 10.9%; P = 0.085) and had more preoperative airway dilatations (86.7% vs 57.7%; P = 0.030). All patients completed pregnancy without complications and ultimately underwent laryngotracheal resection. The expression of hormonal receptors in the surgical specimens was similar in both groups (oestrogen receptors: 100% vs 75% and progesterone receptors: 71.4% vs 72.1%, in pregnancy and non-pregnancy patients, respectively). Airway outcomes were good/excellent in 13 (86.7%) patients with pregnancy-associated ILTS and 225 (90.7%) patients without pregnancy association (P = 0.642), and did not change when adjusting for other risk factors. CONCLUSIONS Pregnancy-associated ILTS is rare. The pathophysiology is unclear, but appearance of symptoms during pregnancy may suggest hormonal factors. To minimize foetal risk, dilatation during pregnancy followed by laryngotracheal resection after delivery is the preferred treatment. Pregnancy association does not seem to affect outcomes with expected satisfactory results in most patients.

Tracheal disease is an infrequent problem requiring surgery. A high index of suspicion is necessary to correctly diagnose the problems. Primary concerns are safe control and assessment of the airway, familiarity with the principles of airway surgery, preserving tracheal blood supply, and avoiding anastomotic tension. A precise reproducible anastomotic technique must be mastered. Operation requires close cooperation with a knowledgeable anesthesia team. The surgeon must understand how to achieve the least tension on the anastomosis to avoid. It is advisable to examine the airway before discharge to check for normal healing and airway patency.

Dr Hassan Najafi, an immigrant from Iran who became the 18th president of The Society of Thoracic Surgeons, died on May 20, 2017. He had also served as chair of the American Board of Thoracic Surgery and the Residency Review Committee for Thoracic Surgery, and was a founding member and first president of the Thoracic Surgery Directors Association. A superb technical surgeon, educator, and investigator, Dr Najafi led the Department of Cardiovascular and Thoracic Surgery at Rush University Medical Center for 25 years. Refined and charismatic, he was wholly devoted to his patients, family, trainees, colleagues, and our profession.

Background Epiphrenic esophageal diverticula are infrequent. Although surgical treatment is generally recommended, technique varies widely and optimal management remains controversial. This study evaluated a single-institution experience for surgical treatment of epiphrenic diverticula. Methods A retrospective review was made of medical records of 31 patients undergoing surgical treatment for epiphrenic diverticula from 1974 to 2016. Results There were 17 men (55%); median age was 65 years. Dysphagia (87%) and regurgitation (71%) were the most common symptoms. Three patients (10%) presented acutely: 2 with ruptured diverticula and 1 with hematemesis. All patients underwent an open transthoracic approach. Diverticulectomy was performed in 28 patients (90%), myotomy in 28 (90%), and a concomitant antireflux procedure in 6 (19%). A total of 22 patients (71%) underwent diverticulectomy and myotomy, 4 (13%) underwent diverticulectomy with myotomy and antireflux procedure, 2 (6%) had myotomy and antireflux, 2 had diverticulectomy alone, and 1 patient had imbrication of the diverticulum after myotomy. Overall, morbidity occurred in 11 patients (35.5%), with major morbidity in 6 (19.4%). There was one postoperative esophageal leak (3%). Ninety-day mortality was zero. Mean follow-up was 30 ± 43 months in 28 patients. Additional procedures (ie, reoperation, balloon dilation) were needed in 7 patients (25%). An excellent outcome (ie, absence of symptoms) was accomplished in 21 patients (75%). Acute presentation was associated with need for further procedures ( p = 0.011) and symptoms at follow-up ( p = 0.011). Conclusions A tailored transthoracic approach to the surgical management of epiphrenic diverticula can provide excellent results. The need for a concomitant antireflux procedure remains controversial and may not be routinely necessary. Acute presentation is associated with poor functional outcome.

Patients with short bowel syndrome lack sufficient functional intestine to sustain themselves with enteral intake alone. Transplantable vascularized bioengineered intestine could restore nutrient absorption. Here we report the engineering of humanized intestinal grafts by repopulating decellularized rat intestinal matrix with human induced pluripotent stem cell-derived intestinal epithelium and human endothelium. After 28 days of in vitro culture, hiPSC-derived progenitor cells differentiate into a monolayer of polarized intestinal epithelium. Human endothelial cells seeded via native vasculature restore perfusability. Ex vivo isolated perfusion testing confirms transfer of glucose and medium-chain fatty acids from lumen to venous effluent. Four weeks after transplantation to RNU rats, grafts show survival and maturation of regenerated epithelium. Systemic venous sampling and positron emission tomography confirm uptake of glucose and fatty acids in vivo. Bioengineering intestine on vascularized native scaffolds could bridge the gap between cell/tissue-scale regeneration and whole organ-scale technology needed to treat intestinal failure patients., There is a need for humanised grafts to treat patients with intestinal failure. Here, the authors generate intestinal grafts by recellularizing native intestinal matrix with human induced pluripotent stem cell-derived epithelium and human endothelium, and show nutrient absorption after transplantation in rats.

Background The purpose of this study was to determine whether computed tomography-guided fiducial placement is a feasible and safe localization procedure to aid resection of small pulmonary nodules. Methods A retrospective review was performed of 20 nodules (mean size 11 mm; range, 6 to 19 mm) referred for preoperative computed tomography-guided fiducial placement in 19 patients (average age 64 ± 11 years; 13 women and 6 men). Results The technical success rate for the placement of fiducials was 95%, with deployment of fiducials into the pleural space in 1 case. Biopsy specimen was obtained at time of the fiducial placement in 4 cases, with sensitivity of 75% and specificity of 100% for malignancy. Two procedures (10%) were complicated by a pneumothorax requiring chest tube placement. The median time between fiducial placement and surgery was 7 days (range, 1 to 123). One to four fiducials were placed a median distance of 0 mm (range, 0 to 7 mm) from the edge of the nodule. Fiducials were identified by on-table fluoroscopy in all cases, and all nodules were completely excised with negative surgical margins. Mean fluoroscopy time was 46 seconds, and mean radiation dose was 12.97 mGy. The final diagnosis was primary lung cancer in 85% of cases, with organizing pneumonia and sarcoidosis accounting for the three benign nodules. Conclusions Computed tomography-guided fiducial placement is a feasible and safe technique that allows biopsy at the time of the procedure and aids localization of small pulmonary nodules during video-assisted thoracic surgery.

Bio-engineered organs for transplantation may ultimately provide a personalized solution for end-stage organ failure, without the risk of rejection. Building upon the process of whole organ perfusion decellularization, we aimed to develop novel, translational methods for the recellularization and regeneration of transplantable lung constructs. We first isolated a proliferative KRT5+TP63+ basal epithelial stem cell population from human lung tissue and demonstrated expansion capacity in conventional 2D culture. We then repopulated acellular rat scaffolds in ex vivo whole organ culture and observed continued cell proliferation, in combination with primary pulmonary endothelial cells. To show clinical scalability, and to test the regenerative capacity of the basal cell population in a human context, we then recellularized and cultured isolated human lung scaffolds under biomimetic conditions. Analysis of the regenerated tissue constructs confirmed cell viability and sustained metabolic activity over 7 days of culture. Tissue analysis revealed extensive recellularization with organized tissue architecture and morphology, and preserved basal epithelial cell phenotype. The recellularized lung constructs displayed dynamic compliance and rudimentary gas exchange capacity. Our results underline the regenerative potential of patient-derived human airway stem cells in lung tissue engineering. We anticipate these advances to have clinically relevant implications for whole lung bioengineering and ex vivo organ repair.

OBJECTIVES Failure of anastomotic healing is a morbid complication after airway or oesophageal surgery. Hyperbaric oxygen therapy (HBOT) has been used extensively in the management of complex wound-healing problems. We demonstrate the use of HBOT to rescue at-risk anastomoses or manage anastomotic failures in thoracic surgery. METHODS Retrospective review of 25 patients who received HBOT as part of the management of tracheal or oesophageal anastomotic problems during 2007–2018. HBOT was delivered at 2 atm with 100% oxygen in 90-min sessions. RESULTS Twenty-three patients underwent airway resection and reconstruction while 2 patients underwent oesophagectomy. There were 16 (70%) laryngotracheal and 7 (30%) tracheal resections. Necrosis at the airway anastomosis was found in 13 (57%) patients, partial dehiscence in 2 (9%) patients and both in 6 (26%) patients. HBOT was prophylactic in 2 (9%) patients. Patients received a median of 9.5 HBOT sessions (interquartile range 5–19 sessions) over a median course of 8 days. The airway anastomosis healed in 20 of 23 (87%) patients. Overall, a satisfactory long-term airway outcome was achieved in 19 (83%) patients; 4 patients failed and required reoperation (2 tracheostomies and 1 T-tube). HBOT was used in 2 patients after oesophagectomy to manage focal necrosis or ischaemia at the anastomosis, with success in 1 patient. Complications from HBOT were infrequent and mild (e.g. ear discomfort). CONCLUSIONS HBOT should be considered as an adjunct in the management of anastomotic problems after airway surgery. It may also play a role after oesophagectomy. Possible mechanisms of action are rapid granulation, early re-epithelialization and angiogenesis.

Background To evaluate the management, complications of treatment, and outcomes of postintubation tracheal stenosis. Methods A retrospective review was performed of records from a prospective database of all patients undergoing tracheal or laryngotracheal resection from 1993 to 2017 for postintubation tracheal stenosis. Redo operations after failure of initial resection and reconstruction for postintubation tracheal stenosis were included. Results There were 392 patients whose ages ranged from 3 months to more than 84 years. A tracheostomy was performed in 275 as part of their care before surgery (present at time of resection in 123), dilations in 201, laser treatment in 82, T tubes in 66, and stents in 44 patients. Median length of resection was 3 cm. Laryngeal release was required in 15 of 392 (3.8%). Operative mortality was 0.8% (3 of 392); T tubes, tracheostomy present at resection, requirement for postoperative tracheostomy, and laryngeal involvement adversely impacted outcomes. Patients having tracheal resection and reconstruction had good or satisfactory outcomes in 96% (289 of 301) compared with 85% (77 of 91) having laryngotracheal resection. Complications within 30 days and at more than 30 days occurred in 116 patients and 14 patients, respectively. There were 96 anastomotic complications—68% minor (65 of 96), and 32% major (31 of 96). Necrosis of cartilage occurred in 12 patients and dehiscence in 14 patients. Conclusions Despite advances in care postintubation tracheal stenosis remains a challenging problem. Laryngotracheal resection and tracheostomy lead to worse outcomes. Excellent surgical results can be obtained for postintubation tracheal stenosis. Good results require careful evaluation, management of comorbid conditions, meticulous technique, minimizing tension, and preservation of blood supply.

Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy.This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012).An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810).MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.

Pulmonary resections with concomitant circumferential airway resection and resection and reconstruction of carina and main stem bronchi remain challenging operations in thoracic surgery. Anastomotic complications range from mucosal sloughing and formation of granulation tissue, anastomotic ischemia promoting scar formation and stricture, to anastomotic breakdown leading to bronchopleural or bronchovascular fistulae or complete dehiscence. Careful attention to patient selection and technical detail results in acceptable morbidity and mortality as well as good long-term survival. In this article, we focus on the technical details of the procedures, how to avoid complications and most importantly how to manage complications when they occur.

Immune checkpoint inhibitors are emerging as therapeutic options for oncology patients in whom conventional treatment regimens have failed. These immunotherapies counteract tumor-induced tolerance and have been shown to be effective in thoracic malignancies, including non-small cell lung cancer (NSCLC). This report highlights the successful use of nivolumab—an immunotherapeutic agent that binds to proteins involved in T-cell proliferation—for the management of recurrent tracheal squamous cell cancer after exhaustion of conventional surgical, chemotherapeutic, and radiation therapy options. Observations provide a strong indication of the potential value of checkpoint inhibitors for managing a wide array of thoracic malignancies.

Objective Pulmonary nodules found incidentally or by lung cancer screening differ in prevalence, risk profile, and diagnostic intervention. The results of surgical intervention for incidental versus screening lung nodules during multidisciplinary Pulmonary Nodule and Lung Cancer Screening Clinic (PNLCSC) follow-up have not been reported. Methods All patients evaluated at a PNLCSC from 2012 to 2018 following referral by primary care physicians, specialist physicians, or self-referral after computed tomography (CT) identified nodules on routine diagnostic CT (incidental group) or lung cancer screening CT (screening group) were included. Follow-up interval, invasive intervention, histology, postoperative events, survival, and recurrence were compared. Results Of 747 patients evaluated in the PNLCSC, 129 (17.2%) underwent surgical intervention. The surgical cohort consisted of 104 (80.6%) incidental and 25 (19.3%) screening patients followed over a mean of 122 and 70 days, respectively. More benign lesions were excised in the incidental group (20.2%, 21/104)—representing 3.3% (21/632) of all incidental nodules evaluated—than in the screening group (4%, 1/25) (P = .038). Operative mortality was zero. Among 99 patients with primary lung cancer, 87% (screening) and 86.8% (incidental) were pathologic stage Ia. Complete follow-up was available in 725 of 747 (97%), and no patient developed progressive disease. Disease-free survival at 5 years was 74.9% (incidental) and 89.3% (screening) (P = .48). Conclusions A unique multidisciplinary PNLCSC for incidental and lung cancer screening–detected nodules with individualized risk assessment reliably identifies primary and metastatic tumors while exposing few patients to diagnostic excision for benign disease. Longer-term outcomes, strategies to limit radiation exposure, and cost control need further study.

Background: Tracheal substitutes remain an active area of research. For rare patients with large or complex defects that cannot be repaired primarily, replacement of the airway may represent the only treatment option. The present systematic review aims to assess the clinical successes and setbacks of current methods of airway replacement. Methods: Systematic review using Medline and PubMed from 01 January 2000 to 01 October 2017 focusing on clinical translation of circumferential or near circumferential (>270°) tracheal substitutes. Studies were identified using key phrases including terms such as “tracheal replacement”, “tracheal regeneration”, “tracheal transplant”, “tracheal tissue engineering”, and “tracheal substitution”. Animal or non-clinical studies were excluded. Reviews were included if they contained clinical updates. Results: Twenty-one studies were included in assessment comprising a mix of case reports, case studies, and a single review with clinical updates on prior studies. Since 2001, 41 patients have undergone a reported circumferential or near circumferential tracheal substitution through four underlying methodologies including allotransplantation, autologous tissue reconstruction, bioprosthetic reconstruction, and tissue engineered reconstruction. Each modality has unique advantages and disadvantages with varying success in clinical application. Conclusions: The need for tracheal substitution remains a difficult clinical problem without an ideal prosthetic or graft material. While various modalities have had limited clinical success, further laboratory work is necessary before tracheal substitutes can become widely adopted, especially in the case of tissue engineered conduits, which have been setback by premature clinical translation.

Objectives Complete resection of neoplasms involving the carina are technically challenging and have high operative morbidity and mortality. This study examines the last 2 decades of clinical experience at our institution. Methods Medical records were retrospectively reviewed between 1997 and 2017 to identify all patients who underwent carinal resection. Primary outcome measures include risk factors for complications and overall survival. Results In total, 45 carinal resections were performed with a median follow-up of 3.4 years (interquartile range 0.8-8.5). Procedures included 21 neocarinal reconstructions (48%), 14 right carinal pneumonectomies (30%), 9 left carinal pneumonectomies (20%), and 1 carinal plus lobar resection (2%). Age ranged from 27 to 74 years, and 23 of 45 patients were female. Eight received neoadjuvant chemotherapy and 6 preoperative radiation. Extracorporeal membrane oxygenation and cardiopulmonary bypass were intraoperatively used for 4 patients with no mortality. Four patients underwent superior vena cava resection and reconstruction. Anastomotic complications occurred in 5 patients, all of which were managed conservatively: 1 required stent placement and a second underwent hyperbaric oxygen therapy. Postoperative events were observed in 26 patients (58%), including pneumonia (n = 11), blood transfusion (n = 8), and atrial arrhythmias (n = 8). More serious complications, such as acute respiratory distress syndrome, occurred in 3 patients. Postoperative events were most closely associated with pulmonary resection (P = .040). There were 3 deaths, yielding an overall operative 30- and 90-day mortality of 6.8% and 7%, respectively. Conclusions Despite advances in perioperative management, carinal resection poses challenges for both patient and surgeon. Preoperative chemotherapy, radiation, and concomitant pulmonary resection were associated with increased risk of complications. Patient selection and meticulous surgical technique contribute to reduction in morbidity and mortality.

Aerodigestive defects involving the trachea, bronchi and esophagus are a result of prolonged intubation, operative complications, congenital defects, trauma, radiation and neoplastic disease. The vast majority of these defects may be repaired primarily. Rarely, due the size of the defect, underlying complexity, or unfavorable patient characteristics, primary repair is not possible. One alternative to primary repair is bioprosthetic repair. Materials such as acellular dermal matrix and aortic homograft have been used in a variety of applications, including closure of tracheal, bronchial and esophageal defects. Herein, we review the use of bioprosthetics in the repair of aerodigestive defects, along with the unique advantages and disadvantages of these repairs.

Tracheal resection and reconstruction has been slow to develop in the field of thoracic surgery. The ability to perform a low tension, well-vascularized anastomosis with good outcomes has improved with understanding of tracheal blood supply and the ability to perform tracheal release maneuvers. Laryngeal and suprahyoid release maneuvers can be helpful for cervical tracheal resections, while hilar and pericardial release maneuvers can be beneficial in thoracic tracheal resections. Simple maneuvers such as neck flexion and dissection of the avascular pretracheal plane can also be used to improve anastomotic tension. In this paper, we will review the indications, technical considerations and results of performing cervical and intrathoracic tracheal release maneuvers during tracheal resection and reconstruction.

Tracheobronchomalacia is an uncommon acquired disorder of the central airways. Common symptoms include dyspnea, constant coughing, inability to raise secretions and recurrent respiratory infections. Evaluation includes an inspiratory-expiratory chest computed tomography (dynamic CT), an awake functional bronchoscopy and pulmonary function studies. Patients with significant associated symptoms and severe collapse on CT and bronchoscopy are offered membraneous wall plication. Tracheobronchoplasty is performed through a right thoracotomy. The posterior airway is exposed after the azygous vein is ligated. The posterior wall of the trachea (and usually both main bronchi) is plicated to a sheet of thick acellular dermis (or polypropylene mesh) with a series of 4 mattress sutures of 4-0 sutures from the thoracic inlet to the bottom of the trachea to re-shape the trachea and restore the normal D shape. Patients report generally good results with improvement of their symptoms. Quality of life is usually improved while pulmonary function tests usually are not improved.

Idiopathic subglottic stenosis is a rare condition of unknown etiology characterized by circumferential stenosis in the subglottic larynx and upper trachea. Historically, patients were treated with dilation or ablation, however this approach has proven to be largely palliative and often leads to recurrence and the need for tracheostomy. A single-staged laryngotracheal resection and reconstruction is now the preferred definitive treatment for idiopathic subglottic stenosis and can be performed with excellent patient outcomes and rare subsequent progression of the disease. Avoiding anastomotic tension and devascularization are important technical keys to minimizing complications.

Anatomy as the foundation of surgery is a concept no better exemplified than by the history of tracheal surgery. Incremental advancements in our understanding of the trachea's position, structure, blood supply and adjacent organs each allowed for stepwise improvements in the thoracic surgeon's ability to address upper airway disease. As such, the mastery of tracheal anatomy is fundamental to those clinicians responsible for treating such ailments. In this article, tracheal anatomy is reviewed and points critical to the thoracic surgeon are highlighted. The structure and location of the trachea, the blood supply to the trachea, and the trachea's spatial relationship to critical mediastinal organs are presented. This material provides the groundwork for understanding all aspects of tracheal surgery today.

Bioengineered lungs produced from patient-derived cells may one day provide an alternative to donor lungs for transplantation therapy. Here we report the regeneration of functional pulmonary vasculature by repopulating the vascular compartment of decellularized rat and human lung scaffolds with human cells, including endothelial and perivascular cells derived from induced pluripotent stem cells. We describe improved methods for delivering cells into the lung scaffold and for maturing newly formed endothelium through co-seeding of endothelial and perivascular cells and a two-phase culture protocol. Using these methods we achieved ∼75% endothelial coverage in the rat lung scaffold relative to that of native lung. The regenerated endothelium showed reduced vascular resistance and improved barrier function over the course of in vitro culture and remained patent for 3 days after orthotopic transplantation in rats. Finally, we scaled our approach to the human lung lobe and achieved efficient cell delivery, maintenance of cell viability and establishment of perfusable vascular lumens.

The objective of this study was to evaluate the influence of total number of resected lymph nodes, lymph node ratio, and the number of lymph node stations sampled on prognosis in patients with early stage non-small cell lung cancer (NSCLC) treated with video-assisted thoracoscopic surgery (VATS).Five hundred and fifty patients who underwent VATS lobectomy or segmentectomy for early clinical stage NSCLC were retrospectively analyzed from 2006 to 2012. Disease-free survival (DFS) and overall survival (OS) were compared for cutoff values of total number of resected lymph nodes (RNs) and lymph node stations (LNS) using Kaplan-Meier methods and Cox proportional hazard models.Lobectomy was performed in 493 (90%) patients with a median follow-up of 2.7 years. Median age was 68 (range, 29 to 92 years) and 342 (62%) were female. Pathologic stage I, II, and III was observed in 434 (79%), 80 (14.5%) and 36 (6.5%) patients, respectively. The N0, N1, and N2 pathologic nodal status was observed in 485 (88%), 38 (7%), and 27 (5%) patients, respectively. Nodal upstaging was observed in 11.3% (59 of 550) in the total cohort and 15% (49 of 332) in patients who underwent LNS greater than 3 compared with 5% (10 of 218) in patients with LNS 3 or less (p0.01). Multivariate analysis identified LNS greater than 3 as a negative independent predictor for DFS (hazard ratio 2.36, p = 0.003) and OS (hazard ratio 1.77, p = 0.046).Sampling greater than 3 LNS and greater than 10 RNs was associated with an increase in nodal upstaging. Only LNS greater than 3 was found to be an independent predictor of mortality in VATS lobectomy and segmentectomy in clinical early-stage NSCLC.

In the late 1990s, several federal government health policy decisions threatened the viability of thoracic surgery as a specialty. To respond to such decisions, active participation in political processes was given extremely high priority by the Executive Committee of The Society of Thoracic Surgeons (STS). Creation of the STS Political Action Committee (STS-PAC) in 1997 was a part of the platform of participation. The purpose of the STS-PAC is to enhance the Society's voice and stature in health care policymaking. Although the STS-PAC receives voluntary contributions from STS members, on average, only 10% of STS members contribute to the STS-PAC. For the 2015–2016 election cycle, there were 542 contributors to the STS-PAC totaling $273,000. An annual contribution of $100 from every STS member would put the STS-PAC into the top 10 for medical PACs (whereas currently it is ranked 22nd of 28 in the group of physician and dental association PACs). Despite the relatively small dollar amount the STS-PAC directs, its strategic disbursement of these dollars has yielded impressive results. For example, the STS-PAC was able to use its influence to effectively stop the Centers for Medicare and Medicaid Services from implementing a potentially calamitous rule that would effectively end traditional global surgical payments. Other advocacy successes include providing guidance to the Centers for Medicare and Medicaid Services in developing the national coverage determination for transcatheter aortic valve replacement and structuring its complex reimbursement schedule, and ensuring that a provision was included in the bill that would give the STS National Database access to claims data. The STS-PAC is a principal component of the STS' advocacy armamentarium. Despite the many successes of the STS-PAC, with even modest contributions by more STS members, the STS-PAC could become a leading medical PAC, and would give the STS an even stronger presence and voice in Washington, DC. Clearly, contributing to the STS-PAC provides STS members the opportunity to have a voice and an impact on health policy and the care of their patients.

Background Resection of posterior mediastinal tumors may be complicated by bleeding or neurologic injury. Preoperative spinal angiography of mediastinal tumors has been underreported or not commonly practiced. This study evaluated the selection criteria and outcomes of patients with posterior mediastinal tumors who underwent preoperative angiography and embolization. Methods This was a single-institution retrospective study of patients with posterior mediastinal tumors from 2002 to 2016. Multilevel spinal angiography was performed, with or without selective arterial embolization of vascular supply, in patients selected by thoracic or neurologic surgeons. Results Ten of 87 patients (11%) with posterior mediastinal tumors underwent preoperative angiography. A mean of 11 arteries (range, 2 to 25) were studied. Embolization in 7 of 10 patients successfully occluded 1 to 3 arteries. There was no significant difference in age, sex, body mass index, American Society of Anesthesiologists Physical Status Classification, operative time, operative blood loss, complications, or death between patients with or without angiography. Patients who underwent angiography had larger tumors (1,490 vs 97 cm3, p Conclusions Selective preoperative angiography for evaluation of posterior mediastinal tumors identifies arterial variations, threatened spinal arteries, and targets for embolization. The specific role of angiography and embolization requires further investigation to standardize indications and protocols for the number of arteries examined.

Background Granulomatosis with polyangiitis (GPA) is associated with development of subglottic stenosis in about one-fourth of all patients. Although endoscopic management is the primary treatment method for tracheobronchial stenosis, some patients have refractory disease, and tracheostomy is required. It is unclear if laryngotracheal resection and reconstruction (LTRR) can be safely performed in patients with GPA. Methods A retrospective review was performed of 11 patients with GPA undergoing LTRR. Results Eleven female patients with GPA and a median age of 47 years underwent LTRR. Six patients were diagnosed with GPA after LTRR and had not received any induction immunosuppression regimen. Five patients had received induction immunosuppression regimen and were in clinical remission before LTRR. LTRR was performed with a protective tracheostomy in 3 patients, which was eventually removed in all. There were no major complications and no postoperative deaths. One patient (9%) failed surgical management and had replacement of a permanent tracheostomy 4 months after LTRR. Six patients (55%) required additional tracheal dilations after LTRR. Ten patients (91%) had durable control of symptoms and freedom from tracheostomy with a median follow-up of 9.7 years. Two patients (18%) experienced subsequent lower airway stenoses. Conclusions Surgical treatment of subglottic stenosis in highly selected patients with GPA is effective and associated with minimal morbidity. Although long-term outcomes are encouraging, additional procedures may be necessary, and patients are at risk of experiencing lower airway disease.

Bioengineering of viable, functional, and implantable human lung grafts on porcine matrix.Implantable bioartificial organ grafts could revolutionize transplant surgery. To date, several milestones toward that goal have been achieved in rodent models. To make bioengineered organ grafts clinically relevant, scaling to human cells and graft size are the next steps.We seeded porcine decellularized lung scaffolds with human airway epithelial progenitor cells derived from rejected donor lungs, and banked human umbilical vein endothelial cells. We subsequently enabled tissue formation in whole organ culture. The resulting grafts were then either analyzed in vitro (n = 15) or transplanted into porcine recipients in vivo (n = 3).By repopulating porcine extracellular matrix scaffolds with human endothelial cells, we generated pulmonary vasculature with mature endothelial lining and sufficient anti-thrombotic function to enable blood perfusion. By repopulating the epithelial surface with human epithelial progenitor cells, we created a living, functioning gas exchange graft. After surgical implantation, the bioengineered lung grafts were able to withstand physiological blood flow from the recipient's pulmonary circulation, and exchanged gases upon ventilation during the 1-hour observation.Engineering and transplantation of viable lung grafts based on decellularized porcine lung scaffolds and human endothelial and epithelial cells is technically feasible. Further graft maturation will be necessary to enable higher-level functions such as mucociliary clearance, and ventilation-perfusion matching.