Puja Gaur

Esophageal cancer: Recent advances in screening, targeted therapy, and management

The incidence of esophageal cancer remains on the rise worldwide and despite aggressive research in the field of gastrointestinal oncology, the survival remains poor. Much remains to be defined in esophageal cancer, including the development of an effective screening tool, identifying a good tumor marker for surveillance purposes, ways to target esophageal cancer stem cells as well as circulating tumor cells, and developing minimally invasive protocols to treat early-stage disease. The goal of this chapter is to highlight some of the recent advances and ongoing research in the field of esophageal cancer.

Birth trends and factors affecting childbearing among thoracic surgeons

BACKGROUND As more women enter the thoracic surgery profession, issues affecting childbearing become increasingly important. We set out to assess birth trends and factors affecting childbearing among thoracic surgeons. METHODS A 33-question anonymous survey was sent to women diplomats of American Board of Thoracic Surgery, residents in Thoracic Surgery Residents Association, and members of Women in Thoracic Surgery. Findings were compared with national norms. RESULTS There were a total of 113 respondents (88 women, 25 men). Of 69% (61 of 88) of women and 88% (22 of 25) of men who desired children, 98% (60 of 61) of women versus 50% (11 of 22) of men delayed pregnancy (p < 0.0001). Eighty-two percent (72 of 88) of women versus 60% (15 of 25) of men felt their career would be adversely affected, with 6% (54 of 88) of women versus 16% (4 of 25) of men reporting that pregnancy would be viewed unfavorably among peers (p < 0.03 and p < 0.0001, respectively). Of women of childbearing age, 28% (15 of 54) utilized assisted reproductive technology (national average 12%, p < 0.0002). The total fertility rate was 0.6 ± 0.2 children per woman whereas the national rate was 1.9. The average age at first-childbirth was 34.3 ± 0.7 years, while the national norm was 25.4. CONCLUSIONS Women thoracic surgeons begin their family later in life and have fewer children compared with the national average. These findings are likely related to the perception that their career would be adversely affected and to advanced maternal age. Residency programs and practice groups should strive to develop policies that support childbearing earlier in training as the number of women thoracic surgeons grows.

Bronchopleural fistula and the role of contemporary imaging

One of the most morbid postoperative complications after a lobectomy or a pneumonectomy is a bronchopleural fistula (BPF). The diagnosis and identification of BPF may be challenging, often requiring repeat imaging and invasive tests, including bronchoscopy, thoracoscopic exploration, or even open exploration. The purpose of this article is to review the types and presentations of BPF and to describe the role of noninvasive imaging for diagnosis and surgical treatment planning. We focused on multidetector computed tomography and advanced postprocessing applications such as multiplanar reconstructions, virtual bronchoscopy, and volume rendering images, including minimum-intensity and maximum-intensity projections. Both multidetector computed tomography and nuclear scintigraphy are reliable noninvasive imaging modalities that can be used expeditiously in an outpatient setting and may prove to be a more cost-effective strategy to identify the fistula as well as conduct postoperative surveillance. These modalities can be used for accurate and efficient testing for earlier diagnosis and treatment planning, thereby significantly improving patient outcome. Additional advanced postprocessing techniques using already acquired imaging data can provide complementary information that is both visually accessible and anatomically meaningful for the surgeon. Better understanding of the potential uses and benefits of these techniques will eventually improve the diagnostic accuracy, optimize preoperative planning, and facilitate follow-up for patients with BPF with improved patient outcomes.

Mitral valve repair versus replacement in the elderly: short-term and long-term outcomes.

OBJECTIVE To compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients. METHODS All patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded. RESULTS Overall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P<.02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P=.04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P=.001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P<.10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P=.001) and hospital stay (9 days vs 8 days, P<.01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P=.03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results. CONCLUSIONS Elderly patients with mitral regurgitation who undergo MVP have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR. MVP is a safe and more effective option for the elderly with mitral regurgitation.

Three dimensional model for surgical planning in resection of thoracic tumors

Highlights • 3D printed model can be made of thoracic malignancy by taking CT image of the patient and creating a 3D surface rendered imaging and printing it on 3D printer.• 3D printed model can help counsel the patient about the planned operation.• 3D printed model can help in surgical planning of the resection of complex thoracic tumors.

Endoscopic evaluation of gastric conduit perfusion in minimally invasive Ivor Lewis esophagectomy.

Highlights • Indocyanine green fluorescent imaging enables visualization of gastric conduit perfusion in real time.• Endoscopic ICG fluorescent imaging enables a minimally invasive assessment of gastric conduit perfusion and esophagectomy completion.• Minimally invasive esophagectomy using endoscopic ICG fluorescent imaging is a safe and time efficient procedure.

Esophageal Anatomy as Seen During Endoscopy and Basic Endoscopic Orientation

The art of surgical endoscopy has revolutionized the diagnosis and treatment of gastrointestinal disorders. Gastroenterologists and esophageal surgeons must familiarize themselves with the proper technique of examining a patient for upper endoscopy.

Gastric Emptying Procedure After Esophagectomy

A systematic review of the literature was performed to assess the necessity of a pyloric drainage procedure during an esophagectomy. Fourteen individual studies were identified from the past decade that published patient outcome after undergoing an esophagectomy either with or without a pyloric drainage procedure. Careful analysis demonstrated that pyloric drainage procedure was associated with a non-significant trend for delayed gastric emptying and biliary reflux, while not affecting the incidence of dumping. No correlation was identified between a pyloric drainage procedure and anastomotic leaks, postoperative pulmonary complications, length of hospital stay, and overall perioperative morbidity.