Ryan A. Macke

The Surgical Apgar Score in esophagectomy

OBJECTIVE The Surgical Apgar Score is a validated prognostic tool that is based on select intraoperative variables (heart rate, mean arterial pressure, and blood loss). It has been shown to be a strong predictor of morbidity and mortality in a variety of surgical populations. Esophagectomy for malignancy represents a unique subset of patients at high risk for postoperative complications. This study assessed the ability of a modified esophagectomy Surgical Apgar Score (eSAS) to predict 30-day major morbidity. METHODS A retrospective review included 168 patients who underwent elective esophagectomy for malignant disease at the University of Wisconsin from January 2009 through July 2013. Preoperative patient characteristics, intraoperative details, and short-term outcomes were recorded. Primary outcome was 30-day major morbidity. Univariate and multivariate analyses were performed to determine associations between predictive variables, eSAS, and major morbidity. RESULTS Major morbidity occurred in 35% of cases. Univariate analysis showed that eSAS of 6 or less was strongly associated with major morbidity (unadjusted odds ratio, 2.55; 95% confidence interval, 1.32-4.91; P = .005). Other risk factors included transhiatal technique, body mass index less than 20 or greater than 35 kg/m(2), and history of diabetes mellitus. In multivariate analysis, eSAS of 6 or less remained a strong predictor of postoperative complications (adjusted odds ratio, 3.75; 95% confidence interval, 1.70-8.26; P = .001). CONCLUSIONS The eSAS was strongly associated with 30-day major morbidity after esophagectomy. Prospective studies are needed to determine whether improved outcomes can be achieved with the eSAS for risk-stratified triage and postoperative care modification.

Resident Perceptions of 2-Year Versus 3-Year Cardiothoracic Training Programs

BACKGROUND Resident perceptions of 2-year (2Y) vs 3-year (3Y) programs have never been characterized. The objective was to use the mandatory Thoracic Surgery Residents Association and Thoracic Surgery Directors Association In-Training Examination survey to compare perceptions of residents graduating from 2Y vs 3Y cardiothoracic programs. METHODS Each year Accreditation Council for Graduate Medical Education cardiothoracic residents are required to take a 30-question survey designed by the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association accompanying the In-Training Examination with a 100% response rate. The 2013 and 2014 survey responses of residents graduating from 2Y vs 3Y training programs were compared. The Wilcoxon signed rank test was used to analyze ordinal and interval data. RESULTS Graduating residents completed 167 surveys, including 96 from 2Y (56%) and 71 from 3Y (43%) programs. There was no difference in the perception of being prepared for the American Board of Thoracic Surgery examinations or amount of debt between 2Y and 3Y respondents. There was no difference in intended academic vs private practice. Graduating 3Y residents felt more prepared to meet case requirements and better trained, were more likely to pass their written American Board of Thoracic Surgery examinations, and were less likely to pursue additional training beyond their cardiothoracic residency. CONCLUSIONS There was no difference in field of interest, practice type, and amount of debt between graduating 2Y vs 3Y residents. Respondents from 2Y programs expressed more difficulty in meeting case requirements, whereas residents from 3Y programs felt more prepared for independent practice and had higher American Board of Thoracic Surgery written pass rates.

Clamshell Thoracotomy: A Unique Approach to a Massive Intrathoracic Schwannoma

Schwannomas (neurilemmomas) are benign tumors arising from the Schwann cells of the neural sheath. They are typically well-encapsulated lesions and in the chest they are most commonly seen within the posterior mediastinum, often originating along the intercostal nerves. Several operative approaches have previously been described for the resection of these tumors, including thoracoscopic techniques and posterolateral thoracotomy. We report a case of a massive schwannoma (27 cm, maximum diameter), unresectable by described approaches, which was successfully excised using a clamshell thoracotomy.

Utilization of surgical treatment for local and locoregional esophageal cancer: Analysis of the National Cancer Data Base

Previous studies have suggested that esophagectomy is severely underused for patients with resectable esophageal cancer. The recent expansion of endoscopic local therapies, advances in surgical techniques, and improved postoperative outcomes have changed the therapeutic landscape. The impact of these developments and evolving treatment guidelines on national practice patterns is unknown.

Pharyngeal perforation and tracheopharyngeal fistula caused by foreign body impaction.

Development of a tracheopharyngeal fistula after pharyngeal perforation is an uncommon occurrence. As a result, published guidance for management of this rare type of aerodigestive tract fistula is limited. We describe the workup and management of a traumatic tracheopharyngeal fistula caused by foreign body impaction. A conservative, endoscopic treatment strategy with broad-spectrum antibiotics, transnasal drainage, and covered tracheal stent placement was used. The stent was removed after 4 weeks, and complete closure of the fistula tract was confirmed by endoscopy and contrast esophagram. Although tracheopharyngeal fistulae are rare and operative treatment can be complex, this case demonstrates that conservative management with antibiotics, drainage, and endoscopic stenting can be successful in select patients.

Financial and Temporal Advantages of Virtual Consultation in Veterans Requiring Specialty Care

Background Access to specialty health care in the Veterans Affairs (VA) system continues to be problematic. Given the potential temporal and fiscal benefits of telehealth, the Madison VA developed a virtual consultation (VC) mechanism to expedite diagnostic and therapeutic interventions for Veterans with incidentally discovered pulmonary nodules. Materials and. Methods VC, a remote encounter between referring provider and thoracic surgeon for incidentally discovered pulmonary nodules, was implemented at the Madison VA between 2009 and 2011. Time from request to completion of consultation, hospital cost, and travel costs were determined for 157 veterans. These endpoints were then compared with in-person consultations over a concurrent 6-mo period. Results For the entire study cohort, the mean time to completion of VC was 3.2 d (SD ± 4.4 d). For the 6-mo period of first VC availability, the mean time to VC completion versus in-person consultation was 2.8 d (SD ± 2.8 d) and 20.5 d (SD ± 15.6 d), respectively (p < 0.05). Following initial VC, 84 (53%) veterans were scheduled for virtual follow-up alone; no veteran required an additional office visit before further diagnostic or therapeutic intervention. VA hospital cost was

Minimally Invasive Esophagectomy in a Patient With Tetralogy of Fallot and Right-Sided Aortic Arch

228 per in-person consultation versus

The concept of intraoperative, "unsuspected" N2: It's suspect.

120 per episode for VC - a 47.4% decrease. The average distance form veteran home to center was 86 miles, with an average travel reimbursement of

Digging Deeper to Understand the Challenges of Minimally Invasive Esophagectomy

112 per in-person consultation, versus no travel cost associated with VC. Conclusions VC for incidentally discovered pulmonary nodules significantly decreases time to consultation completion, hospital cost, and veteran travel cost. These data suggest that a significant opportunity exists for expansion of telehealth into additional practice settings within the VA system.

Chest Discomfort and Longstanding Dyspnea on Exertion.

Improvements in surgical technique and perioperative care have resulted in increased long-term survival for patients with congenital heart disease. As these patients begin to reach their later years, clinicians are challenged with determining optimal management of noncardiac diseases in this complex patient population, including surgically treatable malignancies. We present a case of esophageal cancer in a patient with previously repaired tetralogy of Fallot and right-sided aortic arch, treated with neoadjuvant therapy followed by laparoscopic and left thoracoscopic esophagectomy.