Edward Y. Chan

Management of the Solitary Pulmonary Nodule

CONTEXTn- Optimal management of the patient with a solitary pulmonary nodule entails early diagnosis and appropriate treatment for patients with malignant tumors, and minimization of unnecessary interventions and procedures for those with ultimately benign nodules. With the growing number of high-resolution imaging modalities and studies available, incidentally found solitary pulmonary nodules are an increasingly common occurrence.nnnOBJECTIVEn- To provide guidance to clinicians involved in the management of patients with a solitary pulmonary nodule, including aspects of risk stratification, workup, diagnosis, and management.nnnDATA SOURCESn- Data for this review were gathered from an extensive literature review on the topic.nnnCONCLUSIONSn- Logical evaluation and management pathways for a patient with a solitary pulmonary nodule will allow providers to diagnose and treat individuals with early stage lung cancer and minimize morbidity from invasive procedures for patients with benign lesions.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BackgroundPrimary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.MethodsUtilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closurexa0+xa0absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.ResultsA total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29xa0years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the ‘Mesh’ cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the ‘No Mesh’ cohort (pxa0=xa00.362). A reoperation was necessary in 6 patients (6.7%) in the ‘Mesh’ cohort as compared to 3 patients (3.5%) in the ‘No Mesh’ cohort (pxa0=xa00.543).ConclusionsOnlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

Surgery for Tumors of the Heart

Most surgeons will encounter only a handful of primary cardiac tumors outside of myxomas. Approximately 3 quarters of primary cardiac tumors are benign and 1 quarter is malignant. In most cases, cardiac tumors are silent but when symptoms do occur, they are primarily determined by tumor size and anatomical location, not by histopathology. The diagnosis and preoperative imaging relies heavily on multimodal imaging including echocardiography, computed tomography, magnetic resonance imaging, and coronary angiography. Surgical resection is the most common treatment for most simple primary cardiac tumors and for some complex benign tumors. Surgical resection of primary cardiac tumors frequently involves the need for complex cardiac reconstruction, particularly when malignant. Secondary tumors to the heart are 30 times more frequent than primary cardiac tumors, and their incidence is increasing, largely as a result of advances in cancer diagnosis and therapy. Surgical resection is feasible in only a small fraction of highly-selected patients with secondary tumors to the heart. For complex benign tumors-such as paraganglioma or large fibromas-and all primary and secondary malignant tumors, a multidisciplinary cardiac tumor team review in experienced centers of excellence is recommended.

Use of sternal plate for pectus excavatum repair in adults leads to minimal postoperative pain

Abstract Pectus excavatum is a chest wall deformity that results in caved-in or sunken appearance of lower half of anterior chest. Surgical treatment is favored when functional or cosmetic concerns arise. We present a case and series of six patients (mean haller index: 4.28) who had repair with minimal pleural disruption and sternal plate. After a broad bilateral inframammary skin incision, the anterior aspect of sternum is identified and incised. Next, the surgeon hyperextends and fixates the bone in its desired position by applying manual dorsal pressure through a small intercostal incision. Superior and inferior fasciocutaneous flaps are raised and then advanced to reconstruct the soft tissue defect. All patients had durable repair of the chest wall abnormalities and they had minimal pain during the postoperative period. No analgesia medication was necessary 1 month post-operatively. This may provide significantly less pain compared to the Nuss or Ravitch procedures to fix Pectus excavatum.

Enhanced recovery after thoracic surgery reduces discharge on highly dependent narcotics

BackgroundnThere is large prescription drug epidemic in United States. We want to determine if ERATS (enhanced recovery after thoracic surgery) program can reduce discharge on highly dependent narcotics.nnnMethodsnWe performed a retrospective analysis of prospectively collected data on patients who underwent lung resection and foregut procedures on thoracic surgery service over an 8-month time period. Patients underwent preoperative conditioning instructions, multimodal non-narcotic pharmaceutical usage, total intravenous anesthesia (TIVA) and minimizing highly addictive narcotics during the post-operative period. We gathered information on demographics, indication and type of surgery, morbidity, mortality and length of stay. We also recorded the type of pain medication patients were given as a prescription based on the Drug Enforcement Agencys classification schedule.nnnResultsnFifty-two patients underwent lung resection and 54 patients underwent foregut surgery. There were no mortalities in either group. Ten percent of patients after lung surgery and 6% after foregut surgery had a greater than grade II complication. The median length of stay after lung resection was 2 days and foregut surgery was 1 day. Only 10% of patients went home after lung resection and 2% after foregut surgery with a prescription for schedule II narcotics. We found that patients who were on schedule II narcotics prior to surgery all went home with schedule II narcotics.nnnConclusionsnWe found that ERATS program for thoracic surgical cases can reduce the number of patients going home with highly dependent narcotics. This strategy will decrease the availability of highly addictive prescription drugs in the community.

Computed tomography criteria for the use of advanced localization techniques in minimally invasive thoracoscopic lung resection

BackgroundnThe significant improvement of patient outcomes from minimally invasive lung surgery has led to the development of advanced lung nodule localization techniques to help manage patients with small suspicious lung nodules or to help resect patients with small pulmonary metastases. However, there are no clear computed tomography (CT) criteria to guide the use of advanced localization techniques for this group of patients.nnnMethodsnWe conducted a retrospective chart review of patients who had undergone initial wedge resection of single or multiple lung nodules. We collected demographics, surgical information and surgical outcomes as well as CT scan features. Multiple logistic regression was performed to determine which factors were most predictive of the need for advanced localization techniques.nnnResultsnA total of 45 patients (73%) were resected by direct identification alone while 17 patients (27%) required advanced localization techniques. Of those requiring advanced localization, 11 patients had cone beam CT, 3 patients had transbronchial localization using electromagnetic navigation and 3 patients had preoperative CT guided wire localization. Patients requiring advanced localization had significantly smaller lung nodules at 0.8 cm compared to 1.4 cm (P=0.01), nodules that were further away from the pleura at 1.3 cm compared 0.1 cm (P<0.001) and were more likely to have ground glass nodules (P=0.01) compared to patients who were resected by direct identification alone. Multiple logistic regression confirmed that nodule size, distance to pleura and ground glass attenuation were predictive factors for requiring advanced localizing techniques. Every patient was treated with minimally invasive lung resection. A 1.3-cm or greater solitary pulmonary nodule less than 5 mm from the pleura can be removed without advanced techniques with a 96% success rate.nnnConclusionsnOverall, in patients undergoing resection of a suspicious primary or metastatic lung nodule, advanced localization techniques should be considered in those with small non-solid nodules, which are not near the pleural surface on CT scan.

“Five on a Dice” Port Placement Allows for Successful Robot-Assisted Left Pneumonectomy

Background u2003Technology has evolved to facilitate pulmonary resection. The latest technological advances in computer-aided surgery (Da Vinci Xi) allow for more control during pulmonary resection. Case Description u2003A 59-year-old woman presented with two primary tumors of the left upper and lower lung. After induction chemotherapy, patient had a “five on a dice” port placement and technique was used to perform successful robot-assisted pneumonectomy. The patient was discharged home on postoperative day 3 without any complications. Conclusions u2003We have found that the “five on a dice” port placement allows for optimal control of the robot stapler and facilitates successful robot-assisted left pneumonectomy.

Endarterectomy for pulmonary artery sarcoma: Too much, too little, or just right?

From the Department of Surgery, Division of Thoracic Surgery and Allison Family Distinguished Chair of Cardiovascular Research, Department of Cardiovascular Surgery, Division of Cardiac Surgery, Houston Methodist Hospital, Houston, Tex. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 2, 2017; accepted for publication Nov 13, 2017. Address for reprints: Michael J. Reardon, MD, Houston Methodist Hospital, 6550 Fannin, Suite 1401, Houston, TX 77030 (E-mail: mreardon@houstonmethodist.org). J Thorac Cardiovasc Surg 2017;-:1-2 0022-5223/

Management of asymptomatic pulmonary vein aneurysm

36.00 Copyright 2017 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2017.11.039 Michael J. Reardon, MD

Cervical Esophago-Gastric Tubes for Patients with Malignant Ascites

Aneurysm of a pulmonary vein is a rare vascular anomaly that is usually discovered incidentally as a pulmonary nodule or mediastinal mass. Most patients do not have any symptoms but some patients can present with dyspnea, hemoptysis, or cerebral thromboembolism. Proper diagnosis is crucial as to avoid unnecessary testing or surgical procedures. We highlight a case of an asymptomatic 59-year-old female with a pulmonary vein aneurysm presenting as a 1.5 cm right infrahilar nodule on contrast-enhanced CT during evaluation for acute cholecystitis. Further investigation with MRA revealed that it was vascular in nature, and pulmonary angiography showed dilation of the right inferior pulmonary vein with no communication to the pulmonary artery. On serial imaging, there has been no change in the size of the aneurysm. A small non-enlarging pulmonary vein aneurysm should be managed expectantly.