Erin A. Gillaspie

From 3-Dimensional Printing to 5-Dimensional Printing: Enhancing Thoracic Surgical Planning and Resection of Complex Tumors

PURPOSE Three-dimensional (3D) printing of anatomic models for complex surgical cases improves patient and resident education, operative team planning, and guides the operation. Our group describes two additional dimensions. DESCRIPTION The process of 5-dimensional (5D) printing was developed for surgical planning. Pretreatment computed tomography and positron emission tomography scans were reformatted and fused. Selected anatomy from these studies, along with posttreatment computed tomography and magnetic resonance images, were coregistered and segmented. This fused anatomy was converted into stereolithography files for 3D printing. EVALUATION A patient presenting with a complex thoracic tumor was selected for 5D printing. 3D and 5D models were prepared to allow surgical teams to directly evaluate and compare the added benefits of information provided by printing in 5 dimensions. CONCLUSIONS Printing 5D models in patients with complex thoracic pathology facilitates surgical planning, selecting margins for resection, anticipating potential difficulties, teaching for learners, and education for patients.

The risk of acute kidney injury following transapical versus transfemoral transcatheter aortic valve replacement: a systematic review and meta-analysis

Background The aim of this systematic review is to examine the literature for the risk of acute kidney injury (AKI) in patients who underwent transcatheter aortic valve replacement (TAVR) based on transapical (TA) versus transfemoral (TF) approaches. Methods A literature search was conducted utilizing Embase, Medline, Cochrane Database of Systematic Reviews and ClinicalTrials.gov from inception through December 2015. Studies that reported relative risk, odds ratio or hazard ratio comparing the AKI risk in patients who underwent TA-TAVR versus TF-TAVR were included. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random effect, generic inverse variance method. Results Seventeen cohort studies with 5085 patients were enrolled in the analysis to assess the risk of AKI in patients undergoing TA-TAVR versus TF-TAVR. The pooled RR of AKI in patients who underwent TA-TAVR was 2.26 (95% CI 1.79–2.86) when compared with TF-TAVR. When meta-analysis was confined to the studies with adjusted analysis for confounders evaluating the risk of AKI following TAVR, the pooled RR of TA-TAVR was 2.89 (95% CI 2.12–3.94). The risk for moderate to severe AKI [RR 1.02 (95% CI 0.57–1.80)] in patients who underwent TA-TAVR compared with TF-TAVR was not significantly higher. Conclusions Our meta-analysis demonstrates an association between TA-TAVR and a higher risk of AKI. Future studies are required to assess the risks of moderate to severe AKI and mortality following TA-TAVR versus TF-TAVR.

The effects of contrast media volume on acute kidney injury after transcatheter aortic valve replacement: a systematic review and meta-analysis.

The goal of this systematic review was to assess the effects of contrast media volume on transcatheter aortic valve replacement‐related acute kidney injury.

Computed Tomographic Screening for Lung Cancer: The Mayo Clinic Experience

The Mayo Clinic has been involved in screening for lung cancer since the lung cancer project in 1971. The Mayo Clinic recently completed a study of more than 1500 patients with low-dose computed tomographic (CT) screening for lung cancer. Results showed that more than 75% of patients in the screening program had a lung nodule but only a small percentage had lung cancer. As others have found, screening with low-dose CT finds patients with lung cancer at an earlier stage and hopefully will increase the cure rate.

Variability in Integrated Cardiothoracic Training Program Curriculum

BACKGROUND Development of curricula that appropriately progress a resident from medical school graduate to fully trained cardiothoracic surgeon is a key challenge for integrated cardiothoracic training programs. This study examined variability and perceived challenges in integrated curricula. METHODS Responses to the 2016 TSDA/TSRA survey that accompanies the annual in-training exam taken by current cardiothoracic surgery residents were analyzed. Standard statistical methods were utilized to examine trends in participant responses. RESULTS General surgery experience decreased with post-graduate year, whereas cardiac operative experience increased. Rotations in a wide variety of adjunct fields were common. The majority (87%) of respondents reported had dedicated cardiothoracic intensive care unit (ICU) rotations, and surgical ICU and cardiac care unit rotations were less common (68% and 42%, respectively). The most common surgical subspecialty rotations were vascular (94%) and acute care surgery (88%), with a wide range of clinical exposure (ie, 3-44 weeks for vascular). Importantly, 52% felt competition with general surgery residents for experience and 22.5% of general surgery rotations were at hospitals without general surgery residents. Perceived challenges included optimization of rotations (78%), faculty allowing residents to perform case components (60%), faculty teaching in the operating room (29%), and improving surgical experience on general surgery rotations (19%). CONCLUSIONS Significant variation exists in integrated cardiothoracic surgery curricula. Optimization of rotations, access to surgical experience, and integration with general surgery appear to be the most significant perceived challenges. These data suggest that optimization of early clinical and surgical experience within institutions could improve trainee preparedness for senior cardiothoracic surgery training.

Microlobectomy: A Novel Form of Endoscopic Lobectomy

Objective Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices. Methods The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique. Results Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27–82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94–285) minutes and the blood loss was 118 (5–800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range)length of stay was 3(1–44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia. Conclusions We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

Minimally Invasive Approaches to Chest Wall and Superior Sulcus Tumors

The resection of chest wall tumors, including superior sulcus tumors, has traditionally been performed via an open approach given the extent of structures to be removed. Recently, more advanced experience with minimally invasive techniques (both VATS and robotic) have allowed thoracic surgeons to perform these operations through smaller incisions and avoid the trauma to the overlying major muscles of the chest wall. One of the earliest reports of VATS-assisted chest wall resection by Widmann et al. described performance of wedge resection of lung with VATS followed by en bloc removal of ribs 3 and 4 along with the wedge of lung, which was accomplished without the use of rib spreading [1]. More recently, Hennon et al. reported a series of 17 patients who underwent VATS chest wall resection, which comprised 36 % of overall chest wall resections done at their institution from 2007 to 2013 [2]. The utilization of minimally invasive techniques for chest wall resection has become a more common phenomenon, as surgeons explore the ways in which it may benefit patients in terms of postoperative pain and morbidity. The phrase “minimally invasive chest wall resection” (MICWR) is a bit misleading, as any chest wall resection by definition requires the resection of the same amount of bone and intercostal muscle as in an “open” operation; however the method by which this is accomplished can take advantage of some of the same tools and techniques by which VATS surgery is performed, and hence we will use the term since it reduces the morbidity of cutting muscle.

Management of Stage IIIA (N2) Non–Small Cell Lung Cancer

There is no consensus as to the optimal management of IIIA (N2) non-small cell lung cancer, nor for the role of surgery in treating this disease stage. Clinical trial evidence struggles to keep up with technology advancement and the evolution of expert opinion. Despite advances in chemotherapeutic regimens, methods of delivery for radiation, and less invasive surgical techniques, survival for patients with stage IIIA-N2 malignancies remains poor. Further developments in both will stimulate and maintain controversy in the field for years to come.

Now that reimbursement for readmission to the hospital is threatened, we are finally focused on readmissions after esophagectomy

Esophagectomy, regardless of the approach or technique (degree of exposure), carries highs rate of postoperative morbidity and mortality. Large administrative databases report mortalities ranging from 2.7% to as high as 11%, with morbidity rates in many series exceeding 50%. Some of these are minor complications that do not change a patient’s long-term postoperative course; however, major morbidity (reoperation, anastomotic leak, pneumonia, reintubation, ventilation beyond 48 hours) occurs in 24% of patients in the Society of Thoracic Surgeons General Thoracic Surgical Database. The average stay for a patient after esophagectomy is 10.6 days, with this increasing to a mean of 25.6 days in a patient who has had a postoperative complication. 1

Management of Esophageal Perforations and Leaks

Abstract The incidence of esophageal perforations is on the rise, and iatrogenic causes remain the most common and continue to increase in an era of frequent use of endoscopy for diagnostic and therapeutic procedures. Despite many advances in care, the mortality rate for an esophageal perforation remains high, with some series citing 20%. The esophagus passes through the neck, chest and abdomen, so surgeons managing perforations must be experienced with the unique anatomic considerations for approaching a perforation in any of these levels/locations. Many factors must be considered when managing these patients, including acuity of presentation, contamination, size of leak, cause of leak, and comorbid conditions. Those caring for esophageal perforation must be experienced in endoscopic procedures, esophageal resection, and complex esophageal reconstruction.