Sagar Kadakia

Intraoperative electromagnetic navigational bronchoscopic localization of small, deep, or subsolid pulmonary nodules

Background: Localizing small or deep pulmonary nodules or subsolid ground‐glass opacities often is difficult during video‐assisted thoracoscopic surgery (VATS) or robotic‐assisted thoracoscopic surgery (RATS). This can result in larger resections or conversion to thoracotomy. The goal of this study is to evaluate the role of electromagnetic navigational bronchoscopic localization (ENBL) as a safe and accurate intraoperative method to localize small, deep, or subsolid nodules. Methods: This is a single‐institution, single‐surgeon retrospective study of all patients (51) who underwent combined ENBL and resection of 54 nodules between May 2013 and August 2015. Localization was performed by intraoperative ENBL‐guided transbronchial injection of a liquid marker. The liquid marker used was methylene blue, either alone or in addition to indocyanine green and Isovue. A fiduciary also was added in 2 cases. Immediately after localization, the patients underwent VATS for evaluation before proceeding with RATS for anatomical sublobar resection. Results: The mean preoperative largest nodule diameter on computed tomography scan was 13.3 mm (range, 4–44 mm). The mean distance from the surface of the lung to the middle of the nodule was 22 mm (range, 4–38 mm). Thirty‐one nodules were solid (57.4%), whereas 23 were ground‐glass opacities (42.6%). ENBL successfully localized the nodules for initial sublobar resection in 53 of 54 nodules (98.1%). Minimally invasive thoracoscopic surgery was performed successfully in 49 of 51 patients (96.1%), by RATS in 47 (92.2%), and VATS in 2 (3.9%). Two patients required conversion to thoracotomy secondary to extensive adhesions. Of the 54 nodules, final diagnosis was adenocarcinoma in 32 (59.2%), metastatic disease in 7 (13%), squamous cell carcinoma in 2 (3.7%), neuroendocrine tumor in 2 (3.7%), and benign in 11 (20.3%). There were no operative mortalities. Morbidities included acute renal insufficiency in 2 patients and prolonged air leak requiring a Heimlich valve in 3 patients. Mean length of stay was 3.9 days. Conclusions: ENBL is a safe and accurate intraoperative modality for targeted sublobar resection of pulmonary nodules that are deemed difficult to localize.

Current status of the implantable LVAD

With the ongoing shortage of available organs for heart transplantation, mechanical circulatory support devices have been increasingly utilized for managing acute and chronic heart failure that is refractory to medical therapy. In particular, the introduction of the left ventricular assist devices (LVAD) has revolutionized the field. In this review, we will discuss a brief history of the LVAD, available devices, current indications, patient selection, complications, and outcomes. In addition, we will discuss recent outcomes and advancements in the field of noncardiac surgery in the LVAD patient. Finally, we will discuss several topics for surgical consideration during LVAD implantation.

The impact of lungs from diabetic donors on lung transplant recipients

OBJECTIVES We attempted to determine if transplants of lungs from diabetic donors (DDs) is associated with increased mortality of recipients in the modern era of the lung allocation score (LAS). METHODS The United Network for Organ Sharing (UNOS) database was queried for all adult lung transplant recipients from 2006 to 2014. Patients receiving a lung from a DD were compared to those receiving a transplant from a non-DD. Multivariate Cox regression analysis using variables associated with mortality was used to examine survival. RESULTS A total of 13 159 adult lung transplants were performed between January 2006 and June 2014: 4278 (32.5%) were single-lung transplants (SLT) and 8881 (67.5%) were double-lung transplants (DLT). The log-rank test demonstrated a lower median survival in the DD group (5.6 vs 5.0 years, P = 0.003). We performed additional analysis by dividing this initial cohort into two cohorts by transplant type. On multivariate analysis, receiving an SLT from a DD was associated with increased mortality (HR 1.28, 95% CI 1.07–1.54, P = 0.011). Interestingly, multivariate analysis demonstrated no difference in mortality rates for patients receiving a DLT from a DD (HR 1.12, 95% CI 0.97–1.30, P = 0.14). CONCLUSIONS DLT with DDs can be performed safely without increased mortality, but SLT using DDs results in worse survival and post-transplant outcomes. Preference should be given to DLT when using lungs from donors with diabetes.

Examining Mortality and Rejection in Combined Heart–Lung Transplantations

Background There is a paucity of data on outcomes related to combined heart‐lung transplantations (HLTs). Our objective was to identify variables associated with mortality and rejection in HLT. Methods The United Network for Organ Sharing database was reviewed for HLT performed between 1993 and 2008. Long‐term survivors (survival > 5 years) were compared with short‐term survivors (survival < 5 years). Factors associated with rejection were examined. Risk‐adjusted multivariable Coxs proportional hazards regression analysis was performed to examine variables associated with mortality and rejection. Results Multivariable analysis revealed that recipient male gender was associated with mortality at 1 year (hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.11‐2.54, p = 0.01) and 5 years (HR: 1.41, 95% CI: 1.05‐1.89, p = 0.02). Preoperative extracorporeal membrane oxygenation (ECMO) was associated with mortality at 1 year (HR: 7.55, 95% CI: 2.55‐22.30, p < 0.01) and 5 years (HR: 3.14, 95% CI: 1.19‐8.32, p = 0.02). Preoperative mechanical ventilation (MV) was associated with mortality at 1 year (HR: 3.51, 95% CI: 1.77‐6.98, p < 0.01) and at 5 years (HR: 2.70, 95% CI: 1.51‐4.85, p < 0.01). Multivariable analysis showed that male gender (HR: 1.78, 95% CI: 1.03‐3.09, p = 0.04) and cytomegalovirus (CMV) positivity in the recipient and donor (HR: 3.09, 95% CI: 1.59‐6.01, p < 0.01) were associated with rejection. Clinical infection in the donor (HR: 2.05, 95% CI: 1.16‐3.61, p = 0.01) was also associated with rejection. Conclusion Survival was affected by recipient male sex and need for preoperative ECMO or MV. Risk factors for rejection included male sex, CMV positivity in the donor and recipient, and donor with clinical infection.

Venovenous Extracorporeal Membrane Oxygenation in Two Morbidly Obese Patients

Case studies on the use of venovenous extracorporeal membrane oxygenation in the obese patient have been infrequently reported. We report the successful utilization of venovenous extracorporeal membrane oxygenation in two obese patients with acute respiratory distress syndrome. The first patient had a body mass index of 93 and developed acute respiratory distress syndrome in the setting of pneumonia and aspiration while the second patient had a body mass index of 47 and developed acute respiratory distress syndrome in the setting of gastrografin aspiration. Both were successfully managed with venovenous extracorporeal membrane oxygenation and discharged from the hospital.