Vishnu Ambur

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.

Postoperative outcomes with cholecystectomy in lung transplant recipients.

INTRODUCTION There is a paucity of data on outcomes for lung transplant (LT) recipients requiring general surgery procedures. This study examined outcomes after cholecystectomy in LT recipients using a large database. METHODS The National Inpatient Sample Database (2005-2010) was queried for all LT patients requiring laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). RESULTS There were a total of 377 cholecystectomies performed in LT patients. The majority were done for acute cholecystitis (n = 218; 57%) and were done urgently/emergently (n = 258; 68%). There were a total of 304 (81%) laparoscopic cholecystectomies and 73 (19%) OC. There was no difference in age when comparing the laparoscopic and open groups (53.6 vs 55.5 years; P = .39). In addition, the Charlson Comorbidity Index was similar in the 2 groups (P = .07). Patients undergoing OC were more likely to have perioperative myocardial infarction, pulmonary embolus, or any complication compared with the laparoscopic group. Total hospital charges (

Comparison of open gastrostomy tube to percutaneous endoscopic gastrostomy tube in lung transplant patients.

59,137.00 vs

The impact of lungs from diabetic donors on lung transplant recipients

106,329.80; P = .03) and median duration of stay (4.0 vs 8.0 days; P = .02) were both greater with open compared with LC. CONCLUSION Cholecystectomy can be performed safely in the LT population with minimal morbidity and mortality.

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

Introduction Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG). Methods The National Inpatient Sample (NIS) Database (2005–2010) was queried for all lung transplant recipients requiring OGT or PEG. Results There were 215 patients requiring gastrostomy tube, with 44 OGT and 171 PEG. The two groups were not different with respect to age (52.0 vs. 56.9 years, p = 0.40) and Charlson Comorbidity Index (3.3 vs. 3.5, p = 0.75). Incidence of acute renal failure was higher in the PEG group (35.2 vs. 11.8%, p = 0.003). Post-operative pneumonia, myocardial infarction, surgical site infection, DVT/PE, and urinary tract infection were not different. Post-operative mortality was higher in the PEG group (11.2 vs. 0.0%, p = 0.02). Using multiple variable analysis, PEG tube was independently associated with mortality (HR: 1.94, 95%C.I: 1.45–2.58). Variables associated with survival included age, female gender, white race, and larger hospital bed capacity. Discussion OGT may be the preferred method of gastric access for lung transplant recipients. Conclusions In lung transplant recipients, OGT results in decreased morbidity and mortality when compared to PEG.

Examining Mortality and Rejection in Combined Heart–Lung Transplantations

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.

Venovenous Extracorporeal Membrane Oxygenation in Two Morbidly Obese Patients

Objective Patient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia. Methods The National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications. Results The Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12‐2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35‐3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06‐1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08‐1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39‐2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09‐1.61; P < .01). Conclusions CKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.

IP205. Outcomes After Open Lower Extremity Revascularization in Patients With Chronic Kidney Disease

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.

Does socioeconomic status predict outcomes after cholecystectomy

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.