Jeremiah T. Martin

Impact of the Surgical Technique on Pulmonary Morbidity After Esophagectomy

BACKGROUND Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors. METHODS We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality. RESULTS A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality. CONCLUSIONS Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

Minimally invasive esophagectomy: a teaching hospital's first year experience

Surgical resection of the esophagus remains the mainstay of treatment for esophageal cancer. However, esophagectomy is associated with significant morbidity and mortality in the postoperative period. We have recently altered our practice pattern to include minimally invasive esophagectomy (MIE) as the approach of choice in the hope of minimizing morbidity associated with this procedure. In this retrospective analysis, we compare outcomes of our first year performing MIE to the previous 3 years of open esophagectomy (OE) at a single teaching hospital. Sixty-five patients underwent esophagectomy between June 2002 and July 2006. Among these, 22 patients underwent MIE between June 2005 and July 2006 and 43 patients underwent OE. The two groups were comparable with regards to age, comorbidities and pathologic stage. The MIE group had less operative blood loss (178 mL vs. 356 mL), decreased respiratory complications requiring mechanical ventila-tion (5% vs. 23%), increased number of lymph nodes procured per procedure (15 vs. 8), and increased number of patients discharged within 10 days (72% vs. 28%) when compared to the OE group. No difference was identified in mortality, complications, or length of stay.

Identification of patients with postoperative complications who are at risk for failure to rescue.

IMPORTANCE A minority of patients who experience postoperative complications die (failure to rescue). Understanding the preoperative factors that lead to failure to rescue helps surgeons predict and avoid operative mortality. OBJECTIVE To provide a mechanism for identifying a high-risk group of patients with postoperative complications who are at a substantially increased risk for failure to rescue. DESIGN, SETTING, AND PATIENTS Observational study evaluating failure to rescue in patients entered into the American College of Surgeons National Surgical Quality Improvement Program database. The large sample of surgical patients included in this study underwent a wide range of operations during a 5-year period in more than 200 acute care hospitals. We examined and identified patients at high risk for failure to rescue using propensity stratification. We also developed a risk-scoring system that allowed preoperative identification of patients at the highest risk for failure to rescue. MAIN OUTCOMES AND MEASURES Risk-scoring system that predicts failure to rescue. RESULTS Of the 1,956,002 database patients, there were 207,236 patients who developed serious postoperative complications. Deaths occurred in 21,731 patients with serious complications (10.5% failure to rescue). Stratification of patients into quintiles, according to their propensity for developing serious complications, found that 90% of operative deaths occurred in the highest-risk quintile, usually within a week of developing the initial complication. A risk-scoring system for failure to rescue, based on regression-derived variable odds ratios, predicted patients in the highest-risk quintile with good predictive accuracy. Only 31.8% of failure-to-rescue patients had a single postoperative complication. Perioperative deaths increased exponentially as the number of complications per patient increased. Patients with complications who had surgical residents involved in their care had reduced rates of failure to rescue compared with patients without resident involvement. CONCLUSIONS AND RELEVANCE Twenty percent of high-risk patients account for 90% of failure to rescue (Pareto principle). More than two-thirds of patients with failure to rescue have multiple complications. On average, a few days elapse before death following a complication. A risk-scoring system based on preoperative variables predicts patients in the highest-risk category of failure to rescue with good accuracy. In high-risk patients who develop complications, our results suggest that early intervention, preferably in a high-level intensive care facility with a surgical training program, offers the best chance to reduce failure-to-rescue rates.

The Impact of Laparoscopy on the Volume of Open Cases in General Surgery Training

OBJECTIVE The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years. DESIGN The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed. SETTING ACGME database (1999-2008). MAIN OUTCOME MEASURES Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period. RESULTS Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively. CONCLUSIONS In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Nodal Upstaging During Lung Cancer Resection Is Associated With Surgical Approach.

BACKGROUND Recent reports indicate that thoracoscopic lobectomy for lung cancer may be associated with lower rates of surgical upstaging. We queried a statewide cancer registry for differences in upstaging rates and survival by surgical approach. METHODS The Kentucky Cancer Registry (KCR) collects data, including centralized pathology reporting, on cancer patients treated statewide. We performed a retrospective review from 2010 to 2012 to examine clinical and pathologic stage. We assessed rates of upstaging and whether the surgical approach, thoracotomy (THOR) versus minimally invasive techniques (video-assisted thoracic surgery; VATS), had an impact on final pathologic stage and survival. RESULTS The KCR database from 2010 to 2012 contained information on 2830 lung cancer cases, 1964 having THOR procedure and 500 having VATS resections. Preoperatively, 36.4% of THOR were clinically stage 1a versus 47.4% VATS (p = 0.0002). Of these, final pathologic stage remained stage 1a in 30.5% of THOR procedures and 38.0% of VATS (p = 0.0002). The overall nodal upstaging rate for THOR was 9.9% and 4.8% for VATS (p = 0.002). Decreased nodal upstaging was found with VATS, independent of tumor size and extent of resection (odds ratio 0.6, 95% confidence interval [CI]: 0.387 to 0.985, p = 0.04). However, improved survival was found with VATS compared with THOR (hazard ratio 0.733, 95% CI: 0.592 to 0.907, p = 0.0042). CONCLUSIONS Consistent with other reports, we report a lower upstaging rate with VATS. Nevertheless, there is a survival advantage in VATS patients. Although selection bias may play a role in these observed differences, the improved quality of life measures associated with VATS may explain survival improvement despite lower surgical upstaging.

Preoperative mild-to-moderate coronary artery disease does not affect long-term outcomes of lung transplantation.

Background Coronary artery disease has a high prevalence among lung transplant recipients and has historically been a contraindication to transplant at many institutions. In patients with mild-to-moderate coronary artery disease (Mod-CAD) undergoing lung transplant, outcomes are not well defined. Methods All patients who underwent pulmonary transplantation from January 1996 through November 2010 with pretransplant coronary angiogram were included in our study. Recipients of multivisceral, redo, and lobar lung transplants and those who underwent pretransplant coronary revascularization were excluded. Patients were grouped into Mod-CAD or no-coronary artery disease group (No-CAD). Primary end point was overall survival. Secondary end points were 30-day events and the need for posttransplant coronary revascularization. Results Approximately 539 patients were included in the study: 362 in the No-CAD, 177 in the Mod-CAD group. Patients with Mod-CAD were predominantly male, older, and had a higher body mass index. No difference in either perioperative morbidity and mortality (Mod-CAD, 4.2% vs. No-CAD 3.3%, P=0.705) or late overall mortality was shown between groups. Mod-CAD patients had a shorter hospitalization (median: 12 days vs. 14 days, P=0.009) and required a higher rate of late coronary revascularization procedures (PCI: Mod-CAD vs. No-CAD, 0.3% vs. 4.0%, P=0.0035; CABG: Mod-CAD vs. No-CAD, 0.3% vs. 2.3%, P=0.0411). Conclusions Mod-CAD does not appear to be associated with increased perioperative morbidity or decreased survival after transplant. Coronary artery disease may worsen and require coronary revascularization in patients with risk factors for disease progression. In these patients, close follow-up and screening for progression of coronary artery disease may help prevent late cardiac morbidity.

Coronary revascularization in lung transplant recipients with concomitant coronary artery disease.

Coronary artery disease (CAD) is not uncommon among lung transplant candidates. Several small, single‐center series have suggested that short‐term outcomes are acceptable in selected patients who undergo coronary revascularization prior to, or concomitant with, lung transplantation. Our objective was to evaluate perioperative and intermediate‐term outcomes in this patient population at our institution. We performed a retrospective, observational cohort analysis of 898 lung transplant recipients between 1997 and 2010. Pediatric, multivisceral, lobar or repeat transplantations were excluded, resulting in 791 patients for comparative analysis, of which 49 (median age 62, 79.6% bilateral transplant) underwent concurrent coronary artery bypass and 38 (median age 64, 63.2% bilateral transplant) received preoperative percutaneous coronary intervention (PCI). Perioperative mortality, overall unadjusted survival and adjusted hazard ratio for cumulative risk of death were similar among both revascularization groups as well as controls. The rate of postoperative major adverse cardiac events was also similar among groups; however, concurrent coronary artery bypass was associated with longer postoperative length of stay, more time in the intensive care unit and more postoperative days requiring ventilator support. These results suggest that patients with CAD need not be excluded from lung transplantation. Preferential consideration should be given to preoperative PCI when feasible.

Endobronchial Valves in the Treatment of Persistent Air Leaks

BACKGROUND Endobronchial valves (EBVs) are a useful adjunct in the management algorithm of patients with persistent pulmonary air leaks. They are increasingly used in the management of postsurgical parenchymal air leaks and carry a humanitarian use device exemption for this purpose. We report our experience with EBVs in the management of patients with bronchopleural fistula secondary to postsurgical intervention and spontaneous pneumothorax from medical comorbidities. METHODS An institutional review board-approved retrospective review was conducted of our single-center EBV experience. Patients were categorized as postsurgical versus medical. Data collected included demographic characteristics, indication for and number of valves placed, and chest tube duration before and after valve placement to evaluate overall resolution of air leak. Success was defined as resolution of air leak. RESULTS A total of 14 valve placement procedures were performed. Mean age was 60 years and 10 patients were men. Eight represented prolonged leaks secondary to postsurgical complications and six were secondary to medical comorbidities. Indications for placement of valves in medical patients included persistent leak secondary to lung biopsy, ruptured bleb disease, and pneumothorax after cardiopulmonary resuscitation. Postsurgical indications included leaks secondary to lung biopsy, lobectomy, and ruptured bleb disease. A median of two valves were placed per procedure. A postprocedure median length of stay of 14.5 days was observed in the surgical group compared with 15 days in the medical group. Overall success rate was 57% (surgical group, 62.5%; medical group, 50%). CONCLUSIONS EBVs are a useful adjunct in the management of persistent pulmonary air leaks, particularly when conventional interventions are contraindicated or not ideal. EBVs are well tolerated in the critically ill, have few known complications, are removable, and do not preclude future surgical intervention. Future studies should evaluate EBV efficacy versus the natural course of persistent pulmonary air leaks and their impact on cost and length of stay.

Distinctly perturbed metabolic networks underlie differential tumor tissue damages induced by immune modulator β-glucan in a two-case ex vivo non-small-cell lung cancer study.

Cancer and stromal cell metabolism is important for understanding tumor development, which highly depends on the tumor microenvironment (TME). Cell or animal models cannot recapitulate the human TME. We have developed an ex vivo paired cancerous (CA) and noncancerous (NC) human lung tissue approach to explore cancer and stromal cell metabolism in the native human TME. This approach enabled full control of experimental parameters and acquisition of individual patients target tissue response to therapeutic agents while eliminating interferences from genetic and physiological variations. In this two-case study of non-small-cell lung cancer, we performed stable isotope-resolved metabolomic (SIRM) experiments on paired CA and NC lung tissues treated with a macrophage activator β-glucan and 13C6-glucose, followed by ion chromatography–Fourier transform mass spectrometry (IC-FTMS) and nuclear magnetic resonance (NMR) analyses of 13C-labeling patterns of metabolites. We demonstrated that CA lung tissue slices were metabolically more active than their NC counterparts, which recapitulated the metabolic reprogramming in CA lung tissues observed in vivo. We showed β-glucan-enhanced glycolysis, Krebs cycle, pentose phosphate pathway, antioxidant production, and itaconate buildup in patient UK021 with chronic obstructive pulmonary disease (COPD) and an abundance of tumor-associated macrophages (TAMs) but not in UK049 with no COPD and much less macrophage infiltration. This metabolic response of UK021 tissues was accompanied by reduced mitotic index, increased necrosis, and enhaced inducible nitric oxide synthase (iNOS) expression. We surmise that the reprogrammed networks could reflect β-glucan M1 polarization of human macrophages. This case study presents a unique opportunity for investigating metabolic responses of human macrophages to immune modulators in their native microenvironment on an individual patient basis.

Identifying Esophagectomy Patients at Risk for Predischarge Versus Postdischarge Venous Thromboembolism

BACKGROUND Current guidelines recommend postoperative venous thromboembolism (VTE) chemoprophylaxis for moderate-risk patients (3% rate or greater) and extended-duration chemoprophylaxis for high-risk patients (6% or greater). Large-scale studies of and recommendations for esophagectomy patients are lacking. This study was designed to evaluate the timing, rates, and predictors of postesophagectomy VTE. METHODS Patients undergoing esophagectomies for cancer were identified from the 2005 to 2012 American College of Surgeons National Surgical Quality Improvement database. Timing and rates of VTE (deep venous thrombosis or pulmonary embolism, or both) were calculated. Events were stratified as predischarge or postdischarge. Perioperative factors associated with 30-day rates of predischarge and postdischarge VTE were analyzed. RESULTS Of 3,208 patients analyzed, the surgical approach was Ivor-Lewis (n = 1,131, 35.3%), transhiatal (n = 945, 29.5%), three-field (n = 587, 18.3%), thoracoabdominal (n = 364, 11.3%), and nongastric conduit reconstruction (n = 181, 5.6%). Rates were 2.0% pulmonary embolism, 3.7% deep venous thrombosis, and 5.1% VTE. Overall median length of stay was 11 days (versus 19 days, p < 0.001, if predischarge VTE). Predischarge VTE occurred on median day 9, whereas postdischarge VTE occurred on day 19 (p < 0.001). Only 17% of VTE occurred after discharge. Multivariate analysis identified being male (odds ratio [OR] 2.09, p = 0.018), white race (OR 1.93, p = 0.004), prolonged ventilation (OR 3.24, p < 0.001), and other major complications (OR 1.90, p = 0.005) as independent predictors of predischarge VTE. Older age (OR 1.06 per year, p = 0.006) and major complications (OR 3.14, p = 0.004) were independently associated with postdischarge VTE. CONCLUSIONS Postesophagectomy VTE occurs in a clinically significant proportion of esophageal cancer patients with identifiable risk factors for predischarge and postdischarge events. Elderly patients and patients with major complications are most likely to benefit from extended-duration chemoprophylaxis.