DuyKhanh P. Ceppa

Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis.

Objective:Using a national database, we asked whether video-assisted thoracoscopic surgery (VATS) lobectomy is beneficial in high-risk pulmonary patients. Background:Single-institution series demonstrated benefit of VATS lobectomy over lobectomy via thoracotomy in poor pulmonary function patients [FEV1 (forced expiratory volume in 1 second) or DLCO (diffusion capacity of the lung to carbon monoxide) <60% predicted]. Methods:The STS General Thoracic Database was queried for patients having undergone lobectomy by either thoracotomy or VATS between 2000 and 2010. Postoperative pulmonary complications included those defined by the STS database. Results:In the STS database, 12,970 patients underwent lobectomy (thoracotomy, n = 8439; VATS, n = 4531) and met inclusion criteria. The overall rate of pulmonary complications was 21.7% (1832/8439) and 17.8% (806/4531) in patients undergoing lobectomy with thoracotomy and VATS, respectively (P < 0.0001). In a multivariable model of pulmonary complications, thoracotomy approach (OR = 1.25, P < 0.001), decreasing FEV1% predicted (OR = 1.01 per unit, P < 0.001) and DLCO% predicted (OR = 1.01 per unit, P < 0.001), and increasing age (1.02 per year, P < 0.001) independently predicted pulmonary complications. When examining pulmonary complications in patients with FEV1 less than 60% predicted, thoracotomy patients have markedly increased pulmonary complications when compared with VATS patients (P = 0.023). No significant difference is noted with FEV1 more than 60% predicted. Conclusions:Poor pulmonary function predicts respiratory complications regardless of approach. Respiratory complications increase at a significantly greater rate in lobectomy patients with poor pulmonary function after thoracotomy compared with VATS. Planned surgical approach should be considered while determining whether a high-risk patient is an appropriate resection candidate.

Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature

BACKGROUND Gastric bypass is a proven treatment option for weight loss and the reduction of medical co-morbid conditions in the obese population. Severe refractory and/or recurrent hypoglycemia can occur, especially in postoperative patients who do not comply with the guidelines for oral glucose consumption. In a very small number of patients, the cause is not dietary indiscretions but, instead, factitious insulin administration or nesidioblastosis. The optimal evaluation and management for these diagnoses is not completely lucid yet important for bariatric surgeons and physicians alike to be familiar. Our objectives were to review the appropriate evaluation and treatment options for etiologies of hypoglycemia after gastric bypass and to create an algorithm that biochemically assesses the etiology of hypoglycemia. The setting was a university hospital in the United States. METHODS We present the cases of 3 patients who developed symptomatic hypoglycemia from distinct etiologies after laparoscopic Roux-en-Y gastric bypass. We also reviewed the current data regarding diagnosis and treatment. RESULTS Each patients evaluation and management is elaborated in detail. We propose a novel algorithm for the biochemical evaluation of hypoglycemia after gastric bypass according to our experience and the review of the literature. CONCLUSION Most cases of symptomatic hypoglycemia that develop in gastric bypass patients are associated with dietary indiscretions. However, a small subset of patients can develop refractory, recurrent, hyperinsulinemic hypoglycemia from factitious insulin administration or nesidioblastosis.

Perioperative management of patients on clopidogrel (Plavix) undergoing major lung resection.

BACKGROUND Management of patients requiring antiplatelet therapy with clopidogrel (Plavix) and major lung resection must balance the risks of bleeding and cardiovascular events. We reviewed our experience with patients treated with clopidogrel perioperatively to examine outcomes, including results of a new strategy for high-risk patients. METHODS Patients who underwent major lung resection and received perioperative clopidogrel between January 2005 and September 2010 were reviewed. Initially, clopidogrel management consisted of discontinuation approximately 5 days before surgery and resumption immediately after surgery. After July 2010, high-risk patients (drug-eluting coronary stent placement within prior year or previous coronary event after clopidogrel discontinuation) were admitted 2 to 3 days preoperatively and bridged with the intravenous glycoprotein IIb/IIIa receptor inhibitor eptifibatide (Integrilin) according to a multidisciplinary cardiology/anesthesiology/thoracic surgery protocol. Outcomes were compared with control patients (matched for preoperative risk factors and extent of pulmonary resection) who did not receive perioperative clopidogrel. RESULTS Fifty-four patients who had major lung resection between January 2005 and September 2010 and received clopidogrel perioperatively were matched with 108 control subjects. Both groups had similar mortality, postoperative length of stay, and no differences in the rates of perioperative transfusions, reoperations for bleeding, myocardial infarctions, and strokes. Seven of the 54 clopidogrel patients were admitted preoperatively for an eptifibatide bridge. Two of these patients received perioperative transfusions, but there were no deaths, reoperations, myocardial infarctions, or stroke. CONCLUSIONS Patients taking clopidogrel can safely undergo major lung resection. Treatment with an eptifibatide bridge may minimize the risk of cardiovascular events in higher risk patients.

Results of Pulmonary Resection: Sarcoma and Germ Cell Tumors

Pulmonary metastasis occurs in as many as 88% and 80% of stage IV patients with sarcoma and germ cell tumors, respectively. Pulmonary metastatectomy may be the only means of rendering a patient disease free. Sublobar resection (wedge or segmentectomy), lobectomy, and pneumonectomy achieve complete resection. Bilateral disease can be resected via staged thoracoscopy/thoracotomy, median sternotomy, or clamshell thoracotomy. Multiple resections and re-resections have resulted in improved survival. Five-year survival rates as high as 35% to 52% for sarcoma and 80% for germ cell tumor can be realized.

Outcomes of a novel intrathoracic esophagogastric anastomotic technique

Objectives Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel “side‐to‐side: staple line‐on‐staple line” (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide‐diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institutions initial 6‐year experience. Methods An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications. Results There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end‐stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P = .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge. Conclusions We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.

Technique of thoracoscopic basilar segmentectomy.

STRATEGY FOR THORACOSCOPIC BASILAR SEGMENTECTOMY Although individual basilar segments may be resected, most basilar resections include all 4 segments (ie, segments 7-10). Computed tomography is used preoperatively to determine lesion size, segment location, the presence of adenopathy, and the presence of metabolically active nodal disease (via positron emission tomography), as well as to ascertain that the lesion is not too close to the superior segment to exclude the option of basilar segmentectomy. Anesthesia is administered in the usual fashion, with single-lung ventilation achieved by double-lumen endotracheal tube or bronchial blocker placement. After bronchoscopy and mediastinosopy (when indicated), single-lung anesthesia is established. The patient is positioned in the lateral decubitus position with slight flexion of the table at the level of the hip. This slight flexion provides splaying of the ribs, improving thoracoscopic access and exposure. The chest is then marked for the placement of thoracoscopic incisions, prepped, and draped.

Operative time in esophagectomy: Does it affect outcomes?

Background: The effect of operative duration on postoperative outcomes of esophagectomy is not well understood. The relationship between operative duration and postoperative complications was explored. Methods: Esophagectomies with gastric reconstruction performed between 2010 and 2015 were queried from the National Surgical Quality Improvement Program. Linear and multivariate regression analyses were used to determine if operative duration correlated with outcomes independent of comorbidities. Subset analysis was performed by the type of esophagectomy. Results: There were 5,098 patients with a median age and operative time of 64 years and 353 minutes, respectively. In the transhiatal group, longer operative times correlated with increased rates of pneumonia, prolonged intubation, unplanned reintubation, septic shock, unplanned reoperation, duration of stay, and mortality. For Ivor‐Lewis esophagectomy, there were similar correlations with postoperative complications but not mortality. With the McKeown approach, there were no correlations between operative duration and postoperative outcomes. Conclusion: Prolonged operative time has an independent adverse impact on postoperative morbidity, which varies by surgical approach. We have identified unique cut points in the operative time for transhiatal (333 minutes) and Ivor‐Lewis esophagectomy (422 minutes), which can be used as a prognostic marker for postoperative outcomes as well as a quality metric in well‐selected patients.

Life threatening nontraumatic tension gastrothorax

Tension gastrothorax is a rare condition, which poses a diagnostic dilemma and can be mistaken for a tension pneumothorax. Awareness of the risk factors, clinical presentation, and radiology findings of tension gastrothorax can help with the prompt identification and successful management of this life‐threatening condition.

Management of Perioperative Anticoagulation in Lung Resection

The perioperative management of anticoagulation in patients undergoing pulmonary resection encompasses multiple topics, inherent in each being the balance between the risks of surgical bleeding versus the risks of thrombosis. To address this topic, we evaluated the available literature for recommendations regarding (1) the use of anticoagulation for venous thromboembolism (VTE) prophylaxis(2), the management of patients on chronic anticoagulation (history of pulmonary embolism, chronic atrial fibrillation, mechanical heart valve, etc.), and (3) the management of patients on acute or chronic antiplatelet therapy (cardiac stents, peripheral vascular stents, etc.). We summarize the available data and provide recommendations on how to contend with each of these scenarios in patients undergoing pulmonary resection.

The role of induction therapy

The incidence of esophageal cancer has been steadily increasing. The 5-year survival of esophageal cancer has minimally improved over the past 30 years. In this article, we review the management of esophageal cancer, focusing on the literature investigating the role of induction chemotherapy and radiation therapy.