Christina L. Greene

Thoracic Duct Ligation for Persistent Chylothorax After Pediatric Cardiothoracic Surgery

BACKGROUND There is considerable literature on incidence and medical management of postsurgical chylothorax in children but little is known about outcomes of thoracic duct ligation (TDL) for patients refractory to medical therapy. METHODS A retrospective review of patients undergoing TDL after cardiothoracic surgery (1992 through 2007) was done. Data on demographics including cardiac morphology, characteristics of chylous drainage, medical management, and post-TDL course were collected. When available, imaging studies of the upper body venous drainage vessels were examined. RESULTS Twenty patients (median age, 0.65 years; range, 0.03 to 11 years; weight, 7.0 kg; range, 2.6 to 30 kg) had a diagnosis of chylothorax made 8.5 days (range, 2 to 118 days) after initial operation. Median duration of pre-TDL medical management was 17.5 days (range, 7 to 69 days). Median drainage for 5 days preceding TDL was 34.5 mL x kg(-1) x d(-1) (range, 15 to 135 mL x kg(-1) x d(-1)) with maximal output of 65 mL x kg(-1) x d(-1) (range, 30 to 200 mL x kg(-1) x d(-1)). After TDL, there was a decrease in median drainage to 13 mL x kg(-1) x d(-1) (range, 4 to 160 mL x kg(-1) x d(-1); p = 0.003). Chest tubes were removed 8.5 days (range, 4 to 34 days) after TDL. There were 4 deaths (none attributed to TDL), 2 treatment failures (post-TDL chest tube drainage > 2 mL x kg(-1) x d(-1) > 14 days), and 2 recurrences (after initial chylothorax resolution and hospital discharge). Three patients had documented upper body venous thrombosis. Univariate analysis demonstrated thrombosis of upper body venous vessels (p = 0.02) and prolonged post-TDL chest tube drainage (p = 0.01) were risk factors for death, treatment failure, or chylothorax recurrence. CONCLUSIONS Thoracic duct ligation leads to a major reduction in chest tube drainage and prompt tube removal in most pediatric patients and should be considered early in refractory postoperative chylothorax. Patients with upper body venous thrombosis associated with chylothorax are at a high risk for failure of TDL and mortality.

Alimentary satisfaction, gastrointestinal symptoms, and quality of life 10 or more years after esophagectomy with gastric pull-up

OBJECTIVE The aim of this study was to evaluate alimentary satisfaction, gastrointestinal symptoms, and quality of life ≥10 years after esophagectomy with gastric pull-up. METHODS Patients who had undergone esophagectomy with gastric pull-up before 2003 were interviewed regarding their alimentary function and completed the Gastrointestinal Quality of Life and RAND short-form, 36-item, questionnaires. RESULTS We identified 67 long-term survivors after esophagectomy and gastric pull-up. Of these, 40 were located, and all agreed to participate. The median age was 75 years, and the median follow-up period was 12 years (interquartile range, 10-19). Most patients (88%) had no dysphagia, 90% were able to eat ≥3 meals/day, and 93% finished ≥50% of a typical meal. The mean alimentary comfort rating was 9 of 10. Dumping, diarrhea ≥3 times/day, or regurgitation occurred in 33% of patients. Six patients (15%) had aspiration episodes requiring hospitalization. The median weight loss after surgery was 26 lbs, and the current median body mass index was 25 kg/m(2). Only 2 patients were underweight (body mass index, <18.5 kg/m(2)). The median Gastrointestinal Quality of Life score was 2.9 of 4. The RAND scores were at the population mean in 1 category (physical function) and above the normal mean in the remaining 7 categories. CONCLUSIONS Long-term nutritional status, quality of life, and satisfaction with eating were excellent after esophagectomy with gastric pull-up. Gastrointestinal side effects were common, but serious complications such as aspiration were uncommon. Pessimism regarding the long-term ability to enjoy a meal and live with a good quality of life after esophagectomy is unwarranted.

Rat Reflux Model of Esophageal Cancer and Its Implication in Human Disease.

Objectives: The epidemiologic shift in esophageal cancer from squamous cell carcinoma to esophageal adenocarcinoma coincided with popularization of proton pump inhibitors and has focused attention on gastroesophageal reflux disease as a causative factor in this shift. The aim of this study is to review the literature on the rat reflux model in an effort to elucidate this phenomenon. Methods: An extensive online literature review (PubMed) was carried out to identify all seminal contributions to the study of esophageal adenocarcinoma using the rat reflux model. Results: The rat reflux model is a validated reproducible model for the development of Barretts esophagus and esophageal adenocarcinoma. Esophageal reflux of an admixture of gastric acid and duodenal juice induces Barretts esophagus followed by adenocarcinoma. A high-pH environment created by surgical gastrectomy or proton pump inhibitor therapy in combination with a high-fat diet seems to potentiate the development of Barretts esophagus and adenocarcinoma. Early surgical intervention to prevent reflux reduces the progression toward esophageal adenocarcinoma. Anti-inflammatory, antioxidant, and nitrate-trapping agents reduce the incidence of tumorigenesis. Conclusions: As in the rat so also in humans, reflux of an admixture of gastric acid and duodenal juice in a high-pH environment induces the development of Barretts esophagus followed by esophageal adenocarcinoma. This has led to the hypothesis that to prevent Barretts esophagus and subsequent esophageal adenocarcinoma in humans, the reflux of an admixture of acid and bile must be controlled before the development of Barretts esophagus by methods other than acid-suppression therapy.

The state of surgical treatment of gastroesophageal reflux disease after five decades.

The impetus to identify and counsel patients with progressive disease regarding the need for surgical therapy is critical. This goes largely unheeded by gastroenterologists due to their lack of confidence in the durability of a fundoplication and concern over the side effects of the operation. Consequently, early referral of a patient with symptoms and signs of progressive disease for surgical therapy is resisted. Further, there is widespread concern that not all surgeons are sufficiently experienced in evaluating esophageal patients, many are not knowledgeable enough to select the proper antireflux procedure, and some are not sufficiently trained to properly perform the procedure. 4,5 Over the last 5 decades, 5 principles of the surgical treatment of GERD have emerged and when followed, lead to a successful outcome in nearly all patients. These principles are: documentation of the diagnosis of GERD; determination of the status of the lower esophageal sphincter (LES) and esophageal body; identification of the patient who is a proper candidate for surgical therapy; selection of the proper surgical procedure; and surgeon awareness of the technical nuances of the procedure. Application of these principles requires surgeons to hone their cognitive, diagnostic, clinical, and surgical skills regarding reflux disease. Errors can lead to surgical failure and the need for repetitive reoperations with the inherent risk of vagal injury and ischemic damage to esophageal and gastric tissues. The last 5 decades of experience have taught that a successful therapeutic outcome is unlikely after 3 failed antireflux operations. 6-8 Consequently, it is imperative that the first operation be performed for the right diagnosis, on the right patient, and by a knowledgeable and capable surgeon. The objective of this review is to describe the current state of surgical treatment for GERD, to expand on how new knowledge about disease progression and LES function has improved our ability to select the appropriate patient for surgical therapy, and to offer a more personalized surgical approach to these patients.

Role of Clinically Indicated Transbronchial Lung Biopsies in the Management of Pediatric Post–Lung Transplant Patients

BACKGROUND Although transbronchial biopsy (TBB) is the definitive method for diagnosing graft dysfunction after pediatric lung transplantation, concern over procedural complications has limited its use. We reviewed our institutional experience with clinically indicated TBB to determine its safety and efficacy with emphasis on how biopsy findings altered management. METHODS A retrospective chart review was done of 61 pediatric lung transplantation patients undergoing 179 TBB procedures. Data were collected on pre-TBB symptoms, pulmonary function testing, and imaging studies. The prebiopsy diagnosis was noted and compared with the findings from TBB to see how frequently treatment changed after biopsy. RESULTS Age at TBB ranged from 2 months to 20 years, with an average of 3 biopsies per patient. There was no procedure-related mortality. The incidence of complications was 9% and included important bleeding with spontaneous resolution in 6% and pneumothorax in 3%. The usual indication for TBB was a change in the chest roentgenogram, frequently accompanied by a decrease in flows on spirometry. The TBB specimens were adequate for pathologic analysis 92% of the time, and a specific pathologic diagnosis could be made in 54% of cases. The findings from TBB altered the clinical management of the patient 64% of the time. CONCLUSIONS In pediatric lung transplant recipients presenting with graft dysfunction, TBB is a low-risk diagnostic procedure that yields clinically useful information in a majority of cases. In our experience, the findings from TBB altered medical treatment in 64% of patients. Treatment was most often changed in the group diagnosed with rejection as the probable cause of graft dysfunction.

The evolution of intraoperative support in lung transplantation: Cardiopulmonary bypass to extracorporeal membrane oxygenation

The report of the first successful clinical heart-lung transplant by Reitz and colleagues at Stanford, and those that followed, ushered in a new enthusiasm for lung transplantation. It was soon recognized that lung transplantation was possible without concomitant heart transplantation, and en bloc double lung transplantation using cardiopulmonary bypass soon evolved. Machuca and colleagues of the University of Toronto compare outcomes of intraoperative extracorporeal membrane oxygenation (ECMO) versus cardiopulmonary bypass (CPB) support in patients undergoing lung transplantation (LTx). This study is the first to address which method of extracorporeal intraoperative support may be superior in LTx, a topic of intense current interest. The matched cohorts (33 ECMO vs 66 CPB) resulted from a 7-year (2007-2013) review of 673 LTxs performed at their Toronto program. Although retrospective and nonrandomized, the study groups are well matched and adequately powered; inclusion and exclusion criteria are sufficiently defined. The contemporary period of LTx began in the late 1980s, following a critical assessment of experimental and clinical results of en bloc double LTx, commonly performed at that time. These investigators determined that en bloc ‘‘double’’ LTx, utilizing a central tracheal anastomosis, was technically feasible but frequently attended with severe airway complications, including dehiscence, necrosis, mediastinitis, sepsis, stenosis, and poor longterm survival. To address this problem, a technical alteration in the airway anastomotic technique was introduced. The en bloc tracheal anastomosis was abandoned for a more easily mastered bilateral sequential bronchial anastomosis. This approach avoided the need for CPB in many patients, reduced postoperative hemorrhage, and practically eliminated the life-threatening complications of airway necrosis and dehiscence. Bilateral sequential LTx, with or

Acute Esophageal Necrosis: A Case Series and Long-Term Follow-Up

Acute esophageal necrosis (AEN) is a rare condition characterized by circumferential necrosis of varying lengths in the intrathoracic esophagus. Endoscopically, this process is manifested as a black esophagus. To date, limited case series exist describing AEN, and none report long-term follow-up. Our objective was to report 3 patients with AEN, all diagnosed within 1 year at a tertiary academic medical center, describing early and long-term outcomes of this rare disease. In the absence of perforation, patients can be managed conservatively with serial esophagogastroduodenoscopy (EGD). Long-term strictures may occur that require dilation.

Pressurized Cadaver Model in Cardiothoracic Surgical Simulation

Simulation is increasingly recognized as an integral aspect of thoracic surgery education. A number of simulators have been introduced to teach component cardiothoracic skills; however, no good model exists for numerous essential skills including redo sternotomy and internal mammary artery takedown. These procedures are often relegated to thoracic surgery residents but have significant negative implications if performed incorrectly. Fresh tissue dissection is recognized as the gold standard for surgical simulation, but the lack of circulating blood volume limits surgical realism. Our aim is to describe the technique of the pressurized cadaver for use in cardiothoracic surgical procedures, focusing on internal mammary artery takedown.

The surgeon's perspective on oesophageal disease, and what it means to pathologists

GERD and its potential complications of Barrett’s oesophagus and oesophageal adenocarcinoma are now the most important disease processes for oesophageal surgeons. A major impact on this disease will likely come from the development of cost-effective screening and diagnostic modalities which identify patients who are at risk for developing oesophageal cancer. The surgical approach to Barrett’s oesophagus and oesophageal adenocarcinoma will continue to evolve in response to advances in ablative therapy and ER. The role of the pathologist, with expertise in the diagnosis of Barrett’s oesophagus, will become more prominent as we better define the histological predictors of oesophageal adenocarcinoma. A collaborative effort between pathologists and surgeons is essential in determining the timing and best approach for interventional therapy.

Tu1535 Endoscopic Ultrasound Staging of Stenotic Esophageal Cancers May Be Unnecessary to Determine the Need for Neoadjuvant Therapy

Introduction Endoscopic ultrasound (EUS) is an essential component of preoperative staging for esophageal cancer and is used to determine which patients should proceed to primary surgical resection or receive neoadjuvant therapy prior to surgery. However, when the EUS scope cannot traverse a tumor, the role of pre-dilatation is controversial due to the risk of perforation.