Allison J. McLarty

Esophageal Resection for Cancer of the Esophagus: Long-Term Function and Quality of Life

BACKGROUND Information on function and quality of life of long-term survivors after esophageal resection for carcinoma is limited. METHODS Between 1972 and 1990, 359 patients underwent esophagectomy for stage I or II esophageal carcinoma at Mayo Clinic. We evaluated long-term function and quality of life in 107 of these patients (81 men and 26 women) who survived 5 or more years. Median age at operation was 62 years (range, 30 to 81 years). The operation performed was an Ivor Lewis resection in 77 patients (72%), transhiatal esophagectomy in 14 (13%), extended esophagectomy in 4 (4%), thoracoabdominal esophagectomy in 4 (4%), and other in 8 (7%). Adenocarcinoma was present in 72 patients (67%), squamous cell carcinoma in 28 (26%), and other in 7 (7%). Thirty-four patients (32%) were in postsurgical stage I, 65 (61%) in stage IIA, and 8 (8%) in stage IIB. Median survival was 10.2 years (range, 5.0 to 23.2 years). Follow-up was complete for all patients. RESULTS Gastroesophageal reflux was present in 64 patients (60%), symptoms of dumping in 53 (50%), and dysphagia to solid food in 27 (25%). Seventeen patients (16%) were asymptomatic. Factors affecting late functional outcome were analyzed. Patients who had a cervical anastomosis had significantly fewer reflux symptoms (p < 0.05). Dumping syndrome occurred more frequently in younger patients (p < 0.05) and women (p < 0.01). Quality of life was assessed separately by the Medical Outcomes Study 36-Item Short-Form Health Survey and compared with the national norm. Scores measuring physical functioning were decreased (p < 0.01). Scores measuring ability to work, social interaction, daily activities, emotional dysfunction, perception of health, and levels of energy were similar. Mental health scores were higher (p < 0.05). CONCLUSIONS We conclude that long-term functional outcome after esophagectomy for esophageal carcinoma is affected by age, sex, and type of reconstruction. Quality of life as judged by the patients is similar to the national norm.

Modeling Stroke Risk After Coronary Artery Bypass and Combined Coronary Artery Bypass and Carotid Endarterectomy

Background and Purpose— The goals of this study were to compare the ability of statewide and institutional models of stroke risk after coronary artery bypass (CAB) to predict institution-specific results and to examine the potential additive stroke risk of combined CAB and carotid endarterectomy (CEA) with these predictive models. Methods— An institution-specific model of stroke risk after CAB was developed from 1975 consecutive patients who underwent nonemergent CAB from 1994 to 1999 in whom severe carotid stenosis was excluded by preoperative duplex screening. Variables recorded in the New York State Cardiac Surgery Program database were analyzed. This model (model I) was compared with a published model (model II) derived from analysis of the same variables using New York statewide data from 1995. Predicted and observed stroke risks were compared. These formulas were applied to 154 consecutive combined CAB/CEA patients operated on between 1994 and 1999 to determine the predicted stroke risk from CAB alone and thereby deduce the maximal added risk imputed to CEA. Results— Risk factors common to both models included age, peripheral vascular disease, cardiopulmonary bypass time, and calcified aorta. Additional risk factors in model I also included left ventricular hypertrophy and hypertension. Risk factors exclusive to model II included diabetes, renal failure, smoking, and prior cerebrovascular disease. Our observed stroke rate for isolated CAB was 1.7% compared with a rate predicted with model II (statewide data) of 1.56%. The observed stroke rate for combined CEA/CAB was 3.9%. When the Stony Brook model (model I) based on patients without carotid stenosis was used, the predicted stroke rate was 2.8%. When the statewide model (model II), which included some patients with extracranial vascular disease, was used, the predicted stroke rate was 3.4%. The differences between observed and predicted stroke rates were not statistically significant. Conclusions— Estimation of stroke risk after CAB was similar whether statewide data or institution-specific data were used. The statewide model was applicable to institution-specific data collected over several years. Common risk factors included age, aortic calcification, and peripheral vascular disease. The observed differences in the predicted stroke rates between models I and II may be due to the fact that carotid stenosis was specifically excluded by duplex ultrasound from the patient population used to develop model I. Modeling stroke risk after CAB is possible. When these models were applied to patients undergoing combined CAB/CEA, no additional stroke risk could be ascribed to the addition of CEA. Such models may be used to identify groups at increased risk for stroke after both CAB and combined CAB/CEA. The ultimate place for CEA in patients undergoing CAB will be defined by prospective randomized trials.

Combined coronary artery bypass and carotid endarterectomy: long-term results.

PURPOSE We determined late survival, freedom from late stroke, and freedom from late cardiac events in patients treated by combined coronary artery bypass and carotid endarterectomy (CAB/CEA). METHODS All patients who underwent CAB/CEA in our institution between January 1994 and December 1999 were identified. Follow-up data were obtained from office records and telephone interviews. Endpoints included death from any cause, stroke, and non-fatal cardiac events (MI, CHF, percutaneous transluminal angioplasty with stenting, redo CAB). Data were expressed in life table format. RESULTS Over a 6-yr period 154 patients had combined CAB/CEA with a 3.9% postoperative stroke rate. Six patients (3.9%) died, leaving 148 patients for follow-up. Average follow-up was 38 +/- 23 months (range: 1-82 months). During the follow-up period two patients (1.4%) had late strokes and 17 patients (11%) had late non-fatal cardiac events. The late mortality rate was 13% (19 patients). Of the late mortalities, four were related to cardiac disease and one to stroke. Using Kaplan-Meier analysis, the 5-yr survival probability was 80 +/- 4.3%. The freedom from late ipsilateral neurologic events was 98 +/- 1.3% at 5 yr. The freedom from late cardiac events was 82 +/- 4.6% at 5 yr. CONCLUSIONS The large majority of patients with combined coronary and carotid artery disease can be expected to live for greater than 5 yr. Therefore, these patients should be considered candidates for prophylactic CEA for stroke prevention, even when their carotid lesions are asymptomatic. Successful CAB/CEA provides good long-term survival and freedom from late cardiac events, as well as excellent freedom from late stroke. Further reduction in perioperative events will make this operative approach even more attractive in patients with combined disease.

Murphy's Button revisited. Clinical experience with the biofragmentable anastomotic ring.

Use of the biofragmentable anastomosis ring (BAR) was attempted in 33 patients at two New York City institutions and employed in 31 instances. Anastomoses performed were end-to-end enterocolic (n = 15), colocolic (n = 15), and side-to-side colocolic (n = 1). Patients ranged in age from 27 to 86 years, with the following diagnoses: primary colon cancer, 15; sessile adenoma, four; colostomy, five; diverticulosis, two; metastatic cancer with obstruction, multiple polyposis, perforated appendiceal mass, malignant carcinoid of appendix, intussuscepting right colon mass, one each. In two instances use of the device was aborted because of concern with the blood supply to the bowel wall in one and tissue edema in another. The average duration of postoperative ileus was 4.7 days. Two patients were subsequently treated for small bowel obstruction thought unrelated to use of the anastomotic device. There were no deaths and no evidence of stricture.

Aortocoronary bypass grafting with expanded polytetrafluoroethylene: 12- year patency

Prosthetic coronary artery bypass conduits are rarely used because the rate of thrombosis is inherently higher than that with autologous conduits. The low medium-term patency rates of prosthetic grafts have restricted their use primarily to patients with inadequate autologous conduits or to selected emergencies. We describe a patient treated with expanded polytetrafluoroethylene who had documented patency 12 years after the operation.

Blood Pressure and Adverse Events During Continuous Flow Left Ventricular Assist Device Support

Background—Adverse events (AEs), such as intracranial hemorrhage, thromboembolic event, and progressive aortic insufficiency, create substantial morbidity and mortality during continuous flow left ventricular assist device support yet their relation to blood pressure control is underexplored. Methods and Results—A multicenter retrospective review of patients supported for at least 30 days and ⩽18 months by a continuous flow left ventricular assist device from June 2006 to December 2013 was conducted. All outpatient Doppler blood pressure (DOPBP) recordings were averaged up to the time of intracranial hemorrhage, thromboembolic event, or progressive aortic insufficiency. DOPBP was analyzed as a categorical variable grouped as high (>90 mm Hg; n=40), intermediate (80–90 mm Hg; n=52), and controlled (<80 mm Hg; n=31). Cumulative survival free from an AE was calculated using Kaplan–Meier curves and Cox hazard ratios were derived. Patients in the high DOPBP group had worse baseline renal function, lower angiotensin-converting enzyme inhibitor or angiotensin receptor blocker usage during continuous flow left ventricular assist device support, and a more prevalent history of hypertension. Twelve (30%) patients in the high DOPBP group had an AE, in comparison with 7 (13%) patients in the intermediate DOPBP group and only 1 (3%) in the controlled DOPBP group. The likelihood of an AE increased in patients with a high DOPBP (adjusted hazard ratios [95% confidence interval], 16.4 [1.8–147.3]; P=0.012 versus controlled and 2.6 [0.93–7.4]; P=0.068 versus intermediate). Overall, a similar association was noted for the risk of intracranial hemorrhage (P=0.015) and progressive aortic insufficiency (P=0.078) but not for thromboembolic event (P=0.638). Patients with an AE had a higher DOPBP (90±10 mm Hg) in comparison with those without an AE (85±10 mm Hg; P=0.05). Conclusions—In a population at risk, higher DOPBP during continuous flow left ventricular assist device support was significantly associated with a composite of AEs.

Simulated laparoscopic sigmoidectomy training: responsiveness of surgery residents.

PURPOSE: This study aimed to evaluate the responsiveness of surgery residents to simulated laparoscopic sigmoidectomy training. METHODS: Residents underwent simulated laparoscopic sigmoidectomy training for previously tattooed sigmoid cancer with use of disposable abdominal trays in a hybrid simulator to perform a seven-step standardized technique. After baseline testing and training, residents were tested with predetermined proficiency criteria. Content validity was defined as the extent to which outcome measures departed from clinical reality. Content-valid measures of trays were evaluated by two blinded raters. Simulator-generated metrics included path length and smoothness of instrument movements. Responsiveness was defined as change in performance over time and was assessed by comparing baseline testing with unmentored final testing. RESULTS: For eight weeks, eight postgraduate year 3/4 residents performed 34 resections. Overall operating time (67 vs. 37 min; P = 0.005), flexure (10 vs. 5 min; P = 0.005), inferior mesenteric vessel (8 vs. 5 min; P = 0.04), and ureter (7 vs. 1 min; P = 0.003) times improved significantly. Content-valid measures from trays remained unchanged. Path length (27,155.2 mm) and smoothness (3,575.5 cm/s3) of instrument movement remained unchanged. There were two bowel perforations and 19 anastomotic leaks. Leak rate decreased from 87% to 12.5%. Strong correlation was found between path length and smoothness of instrument movements (r = 0.9; P < 0.001). There was no correlation between simulator-generated metrics and content-valid outcome measures. Interrater reliability was 1.0 for all measures except anastomotic leak (k = 0.56). There was a linear relationship between residents’ clinical advanced laparoscopic case volume and responsiveness (r = −0.7; P = 0.04). CONCLUSIONS: Simulated laparoscopic sigmoidectomy training affected responsiveness in surgery residents with significantly decreased operating time and anastomotic leak rate.

Does reported funding differ by gender in the surgical literature

Background:It is commonly believed that women surgeons are less likely to be funded and to publish than their male counterparts. According to the American Board of Surgery, currently 13.5% of board-certified surgeons are women. Objective:We compared first authorship and reported funding of original articles in the surgical literature by gender. Methods:We conducted a structured review of all original articles during 2006 from 4 major surgical journals (Annals of Surgery, Archives of Surgery, Surgery, and Journal of the American College of Surgeons). For each article, the gender and academic degree of the first author was determined as well as the study design, type and country of the institution, and source of funding, if any. χ2 tests were used to compare the rates of reported funding, academic degrees, and type of research by gender of author. A multivariate logistic regression model was used to determine the association between gender, degree, country, institution, and study design with funding. Results:Of the 664 original research reports evaluated, 118 (17.8% [95% confidence interval (CI), 15.0–20.9]) were first-authored by women and 522 (78.6% [95% CI, 75.3–81.6]) by men (in 24 [3.6%], the gender of the first author was unknown). Two hundred fifty-eight (38.9% [95% CI, 35.2–42.6]) of the articles reported funding. Funding rates among men and women were not quite significantly different (37.0% vs. 45.8%, difference 8.8%; 95% CI, −1%–19%; P = 0.08). The percentage of randomized clinical trials (RCTs) among men and women first authors was similar (13.4% vs. 13.6%, P = 0.92). Female first authors were less likely to have a medical degree than male first authors (93 of 118 [78.8%] vs. 486 of 519 [93.6%], P < 0.0010). On multivariate analysis, non-RCTs were less likely to be funded than RCTs (odds ratio, 0.25; 95% CI, 0.14–0.40). Conclusions:The percentage of original surgical articles first authored by women is greater than the percentage of female surgeons. Funding rates of original articles were similar among men and women.

Impact of Acute Pulmonary Rejection on Cardiac Function

BACKGROUND Experiments were designed to define cardiac function in dogs with single lung allografts during acute rejection of the allografted lung. METHODS AND RESULTS Left lungs were either autotransplanted (n = 4) or allotransplanted (n = 8) in adult male mongrel dogs. All allotransplanted animals were maintained on triple-drug immunosuppression (cyclosporine, azathioprine, and steroids) for 5 days after the operation. In 4 allotransplanted animals, treatment was discontinued, allowing the animals to reject (usually after a further 3 days; rejecting group); 4 other allotransplanted animals were maintained on immunosuppression for an additional 3 days (immunosuppressed group). Another group of dogs were not operated on but were maintained on the same immunosuppression as the rejecting group (controls). All experimental animals underwent fast computed tomographic scanning with measurement of left ventricular pressure and calculation of ventricular chamber volumes, cross-sectional areas of coronary arteries, myocardial perfusion, and intramyocardial blood volume. Neither cardiac output, left ventricular mass, left ventricular pressure, nor myocardial oxygen consumption was altered during acute rejection of lung allografts. However, left ventricular contractility (systolic elastance, Emax) and ejection fraction were depressed to approximately one half (P < .05) in acutely rejecting animals compared with other groups. The cross-sectional area of the coronary arteries was less in autotransplanted and allotransplanted treated animals than in animals that were not operated on. Cross-sectional area of the coronary arteries was decreased by an additional 30% in the rejecting group (P < .05). CONCLUSIONS The results of this study indicate that acute rejection of a single lung allograft decreases cardiac performance and reduces diameter of coronary arteries in the recipient. Alterations of circulating humoral factors and activated leukocytes may contribute to these changes.

Ventricular Assist Device Implantation Configurations Impact Overall Mechanical Circulatory Support System Thrombogenic Potential.

Ventricular assist devices (VADs) became in recent years the standard of care therapy for advanced heart failure with hemodynamic compromise. With the steadily growing population of device recipients, various postimplant complications have been reported, mostly associated with the hypershear generated by VADs that enhance their thrombogenicity by activating platelets. Although VAD design optimization can significantly improve its thromboresistance, the implanted VAD need to be evaluated as part of a system. Several clinical studies indicated that variability in implantation configurations may contribute to the overall system thrombogenicity. Numerical simulations were conducted in the HeartAssist 5 (HA5) and HeartMate II (HMII) VADs in the following implantation configurations: 1) inflow cannula angles: 115° and 140° (HA5); 2) three VAD circumferential orientations: 0°, 30°, and 60° (HA5 and HMII); and 3) 60° and 90° outflow graft anastomotic angles with respect to the ascending aorta (HA5). The stress accumulation of the platelets was calculated along flow trajectories and collapsed into a probability density function, representing the “thrombogenic footprint” of each configuration—a proxy to its thrombogenic potential (TP). The 140° HA5 cannula generated lower TP independent of the circumferential orientation of the VAD. Sixty-degree orientation generated the lowest TP for the HA5 versus 0° for the HMII. An anastomotic angle of 60° resulted in lower TP for HA5. These results demonstrate that optimizing the implantation configuration reduces the overall system TP. Thromboresistance can be enhanced by combining VAD design optimization with the surgical implantation configurations for achieving better clinical outcomes of implanted VADs.