Ernest G. Chan

The ripple effect of a complication in lung transplantation: Evidence for increased long-term survival risk.

OBJECTIVE Lung transplantation is a life-saving procedure for patients who have end-stage lung disease. The frequency and severity of complications have not been fully characterized. We hypothesized that early in-hospital, postoperative complications decrease long-term survival. METHODS We retrospectively identified in-hospital complications in lung transplant recipients, from the period January 2007 to October 2013. Complications were graded using the extended Accordion Severity Grading System (ASGS). Complications were categorized by event and organ system. Survival analysis was performed (P < .05) using a time-dependent model. RESULTS Among 748 eligible patients, 3381 independent in-hospital, postoperative complications occurred in 92.78% of patients. Median follow-up was 5.4 years. Complications associated with significant decrease in 5-year survival were: renal (hazard ratio [HR] 2.58, 95% confidence interval [CI] 1.40-4.48); hepatic (HR 4.08, 95% CI 2.86-5.82); cardiac (HR 1.95, 95% CI 1.56-2.45). The maximum ASGS of ≥5 (18.5% vs 73.8%), and the weighted ASGS sum >10 (2.5% vs 73.8%), were found to be significant predictors of long-term survival. Multivariate analysis identified a weighted ASGS sum of >10, and renal, cardiac, and vascular complications as predictors of decreased long-term survival. CONCLUSIONS Rigorous delineation of complications after lung transplantation showed that grade 5 ASGS in-hospital postoperative complications, and a weighted ASGS sum >10, were independent predictors of decreased long-term survival well beyond the initial perioperative period. These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation.

Anatomic segmentectomy for non-small cell lung cancer: can we believe the hype?

Since first being intentionally used for treatment of small peripheral lung cancers by Jensik et al. , anatomic segmentectomy has garnered much attention when being considered as treatment for stage I non-small cell lung cancer (NSCLC) (1). Lobectomy has long been considered the standard of care. Support for this notion can be traced back to the findings of the Lung Cancer Study Group (LCSG) published in 1995 which revealed a 3-fold increase in local recurrence rates and decreased survival in patients who had undergone sublobar resection rather than lobectomy (2). However, controversy over these conclusions stemmed from the study’s incorporation of wedge resections in the sublobar group leading many to question whether the same results would hold true when comparing lobectomy to true anatomic segmentectomy. The LCSG study results were further supported by analysis done with the Surveillance Epidemiology and End Results (SEER) database [1998-2007] by our group which showed statistically significant better survival outcomes in patients undergoing lobectomy compared to segmentectomy (3). Nonetheless, anatomic segmentectomy still has gained enthusiasm by many surgical groups. Many investigators have reported equivalent outcomes for anatomic segmentectomy and lobectomy with stage I NSCLC. It is clear that additional studies are needed to define the merits of anatomic segmentectomy for early stage NSCLC. Definitive answers in this area can’t come fast enough when one considers the recent recommendations of CT screening from the National Lung Screening Trial where detection of more early stage peripheral tumors are on the horizon (4).

Trileaflet aortic valve reconstruction using glutaraldehyde fixed autologous pericardium

Aortic valve replacement (AVR) has been considered the gold standard for surgical treatment of aortic stenosis (AS). However, the prostheses used for replacement are not perfect—with mechanical valve requiring anticoagulation and bioprosthetic valves having issues with durability. Recently, there have been an influx of reconstructive techniques. However, these techniques are underutilized due to the complexity of the technique. One of the techniques that has shown promising long-term results is the trileaflet aortic valve reconstruction using glutaraldehyde fixed autologous pericardium. Once the autologous pericardium is fixed in glutaraldehyde, the aortotomy is done. The leaflets of the diseased aortic valve are removed, along with any calcium along the annulus. The commissural distances are then measured using custom sizers which correspond to a template used to sketch out neo-leaflets. The three neo-leaflets are attached using a running 4-0 polypropylene sutures. Once the valve reconstruction is completed, coaptation of the three cusps is checked by using saline and negative pressure on the left ventricular vent. Once the aortotomy is closed and the patient comes off cardiopulmonary bypass, the integrity of the leaflets are once again checked by transesophageal echocardiography. This standardized technique offers excellent long-term results and is reproducible.

Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training

OBJECTIVE Transitioning from medical school and general surgery training to cardiothoracic (CT) surgical training poses unique challenges for trainees and patient care. We hypothesized that participation in technology-enhanced simulation modules that provided early exposure to urgent/emergent CT patient problems would improve cognitive skills and readiness to manage common urgencies/emergencies. DESIGN Traditional and integrated cardiothoracic residents at our institution participated in a technology-enhanced simulation curriculum. The course comprised of didactics, hands-on simulation, virtual models, and mock oral examinations. Residents also were given a validated pretest and post-test to evaluate knowledge retention and integration. Resident performance was graded using a previously validated objective structured clinical examination. Resident perception of course usefulness and relevance was determined through the completion of a perception survey. SETTING This study occurred at the University of Pittsburgh School of Medicine with the Department of Cardiothoracic Surgery. The facility used was the Peter Winter Institute for Simulation, Education and Research. PARTICIPANTS From 2013 to 2015, 25 traditional and integrated cardiothoracic residents participated in these training modules who have completed all portions of the simulation were used for analysis. RESULTS For our participants, knowledge base significantly increased by 7.9% (pretest = 76.0% vs. post-test = 83.9%, p < 0.01). According to trained-rater evaluation, 93.6% of responses to the 11 objective structured clinical examination competencies were deemed adequate. Postcourse perception survey demonstrated 92% of participants scoring the sessions as important or very important toward development and confidence in managing the cardiothoracic scenarios. These findings were present despite historical assumption that these learners were prepared for complex patient care. CONCLUSIONS After completing a technology-enhanced course combining didactics, simulation, and real-time assessment, residents demonstrated objective improvements in cognitive skills and readiness in managing CT patients. Resident postcourse feedback indicated enhanced confidence, suggesting increased preparedness transitioning to CT surgery. This has strong implications for improved patient safety during these potentially labile transition periods.

Bilateral Sequential Lung Transplantation: What the Anesthesiologist Needs to Know About the Surgical Approach

Lung transplantation is a viable option for those patients with end-stage lung disease. After careful evaluation of candidacy, a complex operation with numerous challenging components is performed. Described herein, are the salient features of this operation from the viewpoint of the surgeon. Our goal is to enhance the anesthesiologist’s understanding of the process with a view to improving multidisciplinary collaboration to improve outcomes as a whole.

Rib Fixation Following Trauma: A Cardiothoracic Surgeon's Perspective

The most common result of blunt thoracic injury is indeed the fracture of one or more ribs. Rib fractures consists of nearly 40% of patients admitted to major trauma centers, nearly accounting for 200,000 documented cases in the national trauma databank. This injury is often used as an important indicator of trauma severity and playing a major contributing factor in as many as 50% of fatal cases. What is particularly devastating about rib fractures is their intimacy to many vital structures. The location of the rib fracture may indicate types of injuries that may occur. Patients often present with hemothorax or pneumothorax, particularly if two or more ribs are fractured.

Growing evidence for a weighty problem.

In 1994, work evaluating the effects of the positional cloning of the murine obese gene was especially striking. 1 Mutation of the gene in mice resulted in profound obesity and type 2 diabetes as part of a syndrome that resembled morbid obesity in human beings (Figure 1). Not surprisingly, murine models of obesity have been used subsequently to help parse the relationship between human obesity and several human diseases. Cancer is no exception. There is unquestionable evidence in support of a dramatic relationship between obesity and cancer. In the United States alone, the amount of obese or overweight individuals has reached 65% of the population. 2 With the prevalence of obesity at epidemic levels, the relationship between cancer and obesity has many implications worldwide. Historically, the relationship between obesity and cancers such as those of the breast, colon, liver, and more have been well documented. 3-7 The rise in the incidence of esophageal cancer mirrors the increase in obesity in the population. How these epidemiologic observations are linked at the molecular level remains unclear and complex. The article in this issue of the Journal of Thoracic and Cardiovascular Surgery by Fowler and colleagues 8 attempts to examine the relationship between obesity and EAC further. The importanceinidentifyingtheconnectionbetweenincreasedweight and EAC cannot be stressed enough, especially with the 300%increaseinEACincidencerateoverthepast25years. 9 A strong linear relationship between EAC and increased body mass index, a measurement of obesity, has been identified in the literature. A recent systematic review and meta-analysis of more than 140 studies showed a strong association between a 5-unit increase in body mass index and EAC in both men and women. 10 However, until this