Steven Milman

Risk factors for reinsertion of urinary catheter after early removal in thoracic surgical patients

Objectives: To reduce the incidence of urinary tract infection, Surgical Care Improvement Project 9 mandates the removal of urinary catheters within 48 hours postoperatively. In patients with thoracic epidural anesthesia, we sought to determine the rate of catheter reinsertion, the complications of reinsertion, and the factors associated with reinsertion. Methods: We conducted a prospective observational study of consecutive patients undergoing major pulmonary or esophageal resection with thoracic epidural analgesia over a 2‐year period. As per Surgical Care Improvement Project 9, all urinary catheters were removed within 48 hours postoperatively. Excluded were patients with chronic indwelling catheter, patients with urostomy, and patients requiring continued strict urine output monitoring. Multivariable logistic regression analysis was used to identify independent risk factors for urinary catheter reinsertion. Results: Thirteen patients met exclusion criteria. Of the 275 patients evaluated, 60 (21.8%) required reinsertion of urinary catheter. There was no difference in the urinary tract infection rate between patients requiring reinsertion (1/60 [1.7%]) versus patients not requiring reinsertion (1/215 [0.5%], P = .389). Urethral trauma during reinsertion was seen in 1 of 60 patients (1.7%). After reinsertion, discharge with urinary catheter was required in 4 of 60 patients (6.7%). Multivariable logistic regression analysis found esophagectomy, lower body mass index, and benign prostatic hypertrophy to be independent risk factors associated with catheter reinsertion after early removal in the presence of thoracic epidural analgesia. Conclusions: When applying Surgical Care Improvement Project 9 to patients undergoing thoracic procedures with thoracic epidural analgesia, consideration to delayed removal of urinary catheter may be warranted in patients with multiple risk factors for reinsertion.

Tracheostomy after cardiac surgery: What have we learned?

From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Jan 8, 2017; accepted for publication Jan 12, 2017. Address for reprints: Thomas Ng, MD, 2 Dudley St, Suite 470, Providence, RI 02905 (E-mail: tng@usasurg.org). J Thorac Cardiovasc Surg 2017;-:1 0022-5223/

Efficacy of pre-operative nasal staphylococcus aureus screening and chlorhexidine chest scrub in decreasing the incidence of post-resection empyema.

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.01.021

Robotic tracheobronchoplasty is feasible, but which patients truly benefit?

BACKGROUND We evaluated the efficacy of pre-operative Staphylococcus aureus (SA) screening and chlorhexidine chest scrub in decreasing the incidence of empyema after major pulmonary resections. METHODS For two years, a strategy aimed at decreasing post-resection empyema was instituted. This entailed pre-operative screening for nasal SA and chlorhexidine chest scrub the night before surgery (Group Swab-Scrub, n=192). Patients screened positive for SA, methicillin-resistant (MRSA) and methicillin-sensitive (MSSA), received 5 d of nasal mupirocin. Group Swab-Scrub was compared with patients two years earlier, who did not receive this pre-operative maneuver (Group Control, n=173). The extent of resection considered was lobectomy or greater. All patients received cefazolin (or clindamycin if allergic) prior to incision and 24 h postoperatively, except for patient in Group Swab-Scrub screening positive for MRSA, who received vancomycin. All patients had povidone-iodine skin preparation. RESULTS In Group Swab-Scrub, prevalence of nasal SA was 8.9% (17/192) two with MRSA and 15 with MSSA. There was no difference in patient demographics or operative characteristics between the Group Swab-Scrub and Group Control. There was also no difference in prolonged air-leak, empyema, wound infection, pneumonia, or mortality rates between the two groups. When stratifying for the extent of procedure, there was no difference in the incidence of empyema after lobectomy (Group Swab-Scrub, 3.9% [7/177] versus Group Control, 2.0% [3/151]; p=0.352) or pneumonectomy (Group Swab-Scrub, 6.7% [1/15] versus Group Control, 13.6% [3/22]; p=0.633). In both univariate and multivariable analysis, prolonged air-leak and pneumonectomy were significant risk factors for empyema. CONCLUSIONS Preoperative screening for nasal SA and chlorhexidine chest scrub does not seem to decrease empyema rates after major pulmonary resection. Prolonged air-leak and pneumonectomy continue to be significant risk factors for developing empyema. The number of patients undergoing pneumonectomy in this study is small and further studies are needed for this patient population.

Atrio-oesophageal fistula after the cryomaze procedure

From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Aug 4, 2018; accepted for publication Aug 9, 2018; available ahead of print Sept 20, 2018. Address for reprints: Thomas Ng, MD, 2 Dudley St, Suite 470, Providence, RI 02905 (E-mail: tng@usasurg.org). J Thorac Cardiovasc Surg 2019;157:801-2 0022-5223/

Has the time come to declare video-assisted thoracic surgery lobectomy the standard of care for early stage lung cancer?

36.00 Copyright 2018 by The American Association for Thoracic Surgery https://doi.org/10.1016/j.jtcvs.2018.08.028

Efficacy of preoperative methicillin-resistant staphylococcus aureus screening and chlorhexidine chest scrub in decreasing the incidence of post-resection empyema

We report a case of an atrio-oesophageal fistula after biatrial cryomaze ablation for atrial fibrillation, a complication that has not yet been described in the literature for the cryomaze method. Our report also serves as a reminder of this rare but lethal complication- that it can occur after any method of ablation for atrial fibrillation and a high index of suspicion for its diagnosis must be maintained to allow for early surgical treatment which offers the best chance of survival.

Initial clinical outcomes after completion of training in a Canadian Royal College thoracic surgery program.

In the absence of a well-designed randomized trial, propensity-matched studies are often viewed as the next best level of evidence to guide patient management. Overwhelmingly, published propensity-matched studies from large national databases have all shown the video-assisted thoracic surgery (VATS) approach to be superior to thoracotomy for lobectomy in the surgical treatment of lung cancer. Propensity-matched studies using the Society of Thoracic Surgeons (STS) database (1,2), the American College of Surgeons Oncology Group (ACOSOG) Z0030 study database (3), the American College of Surgeons National Surgical Quality Improvement Program database (4), the Nationwide Inpatient Sample database (5), the surveillance epidemiology and end results (SEER)-medicare database (6), the cancer and leukemia group B (CALGB) 140202 study database (7), the European Society of Thoracic Surgeon database (8), the Premier Prospective Database (9), the French National Database (10), and the National Cancer Data Base (NCDB) (11) have all uniformly shown VATS lobectomy have a lower complication rate and a shorter length of hospital stay when compared with lobectomy by thoracotomy. The current study by Zhao et al. (12) adds to this growing list of published propensity-matched studies that find the VATS approach to be superior.

For Symapthectomy, Age is Just a Number

ESULTS: Optimized AVD-VVD (AVD 188 43 msec, VVD 50 msec) increased average PCO 9 7% (p 0.05) vs. default ettings (AVD 150 msec, VVD 0 msec) and 24 9% (p 0.001) s. the worst settings (AVD 166 36 msec, VVD 31 37 sec). Optimized BIVP increased TCO and MAP in all patients vs. SR. Average TCO increased 17 11% (6.0 1.1 vs. 5.1 0.9 /min; p 0.001), and average MAP increased 11 9% (80 9 vs. 2 9 mmHg; p 0.001). There was no benefit of BiVP vs. AAI p 0.05).