Use of electromagnetic navigational bronchoscopy in robotic pulmonary resection.

Robotic resection of pulmonary lesions has become a more common approach in the field of thoracic surgery. The greatest drawback of robotic resection is the lack of tactile feedback as compared to open approaches, making identification of intrapulmonary lesion difficult. Electromagnetic navigational bronchoscopy (navibronch) enables pre-incisional marking of pulmonary lesions for intraoperative identification. We sought to determine how effective navibronch was in our institution's robotic cases. Thirty-one patients underwent robotically assisted resection of 35 lesions with the assistance of navibronch from 7/2014 to 9/2015. Retrospective demographic and operative data were collected on these patients, and statistical analysis was conducted using ANOVA means testing, Chi-square, and non-parametric tests. The average age in this patient population was 63.7 ± 13.5 years. Eight patients (25.8%) were male. Twenty-five (80.6%) of the patients had pathology involving one lobe, with six (19.4%) in two lobes. 34 of the resections (97.1%) resulted in dye being localized to the first specimen; 34 (97.1%) were found to have the target pathology in the initial specimen. Further resection was carried out in 22 (62.9%) cases, with the final resection resulting in a segment in 2 (5.7%) and a lobe in 14 (40.0%). The mean number of lung specimens collected was 1.94 ± 0.13. The mean number of tumors in each target resection was 1.46 ± 0.66 in final pathology. Malignancy was found in 19 (54.3%) of final specimens. There were no complications related to navibronch. Navibronch is an effective technique in the identification and localization of pulmonary lesions in robotically assisted lung resections.

Initial Outcomes of Symmetrically Flared Covered Nitinol Stents for Esophageal Pathologies.

BACKGROUND: A recently available, low profile, fully covered metal stent with symmetrical flares (FCMSF) may offer improved resistance to migration in esophageal disease. MATERIALS AND METHODS: A retrospective review of 58 esophageal FCMSF placed in 46 consecutive patients was performed. Pathologies included stricture and leak of benign and malignant etiology. RESULTS: Sixteen of 58 stents (28%) were placed urgently/emergently. All patients had successful stent deployment with 0% stent-related hospital mortality. Postoperative morbidity occurred in 15 of the 58 (26%) stents and included stent migration, atrial fibrillation, pneumonia, pneumothorax, urinary retention, hemodynamic instability, and chronic obstructive pulmonary disease exacerbation. In patients with stricture (n=29), mean dysphagia scores were reduced from 3.1±0.6 preoperatively to 1.1±0.8 postoperatively (P<0.001). For leak, stent therapy (±drainage) avoided formal esophageal operation in 95% (21/22). Four stents (6.9%) were removed for stent migration, 2 of which migrated after adjuvant chemoradiation. Adjuvant chemoradiation therapy was an independent risk factor for stent migration (odds ratio=1.6; P=0.02) by multivariable regression analysis. The mean duration of stent therapy was 65±62 days for stricture (27/34 remain in situ) and 57±57 days for leak (10/22 remain in situ). The median hospital length of stay was 2 days. CONCLUSIONS: FCMSF provide a safe and effective therapy for both benign and malignant esophageal dysphagia and leaks. The symmetrical property may contribute to the overall low observed migration rate while still allowing for simple and safe stent retrieval.

Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbrochial needle aspiration.

Endobronchial, ultrasound-guided, transbronchial needle aspiration has recently been introduced as an alternative to mediastinoscopy for lymph node staging of lung cancer and the diagnosis of respiratory diseases. This procedure is less invasive and more cost-effective, and multiple large studies have reported no associated complications. In this case, an individual presented with descending mediastinitis after having this minimally invasive procedure for mediastinal lymphadenopathy.

Video-assisted thoracoscopic lobectomy for pulmonary aspergilloma after life-threatening hemoptysis in a patient with lupus.

Open thoracotomy procedures serve as the mainstay for surgical resection of pulmonary aspergilloma. These procedures are considered among the most challenging for thoracic surgeons, and postoperative morbidity and mortality rates are high. Here, we present patient who underwent video-assisted thoracoscopic lobectomy for aspergilloma. Based on the success of the operation, we suggest that video-assisted thoracoscopic surgical resection be considered as an option for pulmonary aspergilloma.

Initial experience with endobronchial ultrasound in an academic thoracic surgery program.

BACKGROUND: Mediastinoscopy is considered the gold standard for evaluating mediastinal lymph nodes. However, endobronchial ultrasound-guided transbronchial needle aspiration has lately offered a less invasive alternative, with the ability to obtain nodal samples under direct visualization. Recent literature found an early learning curve for this technique. We present the initial experience of 4 thoracic surgeons with the procedure. MATERIALS AND METHODS: A retrospective chart review was performed on the first 51 patients on whom an endobronchial ultrasound-guided transbronchial needle aspiration was performed from January 5, 2007, to July 24, 2008. This group included 43 patients with a history or known diagnosis of malignancy as well as 8 patients with a presumed sarcoidosis diagnosis. All negative results were confirmed with mediastinoscopy. The technique's sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were assessed. RESULTS: A total of 73 lymph nodes underwent biopsy in 51 patients. These individuals included 34 men and 17 women, with an average age of 62 years (range, 21-89 years). No surgical or postoperative complications were noted. Overall, a correct diagnosis was established in 88% of the patients (45 of 51). After the first 25 cases (a mean of 6 cases per surgeon), a technique modification was adapted to increase diagnostic yield. The first 25 cases had a 72.22% sensitivity and 80% accuracy, whereas the last 26 cases had a 95.45% sensitivity and 96.15% accuracy (P = .07). CONCLUSION: Endobronchial ultrasound-guided transbronchial needle aspiration is a quickly mastered technique that offers a safe, minimally invasive, and accurate means to evaluate mediastinal lymph nodes.

Local surgical, ablative, and radiation treatment of metastases.

Because local therapies directed toward a specific tumor mass are known to be effective for treating early-stage cancers, it should be no surprise that there has been considerable historical experience using local therapies for metastatic disease. In more recent years, increasing interest in the use of local therapy for metastases likely has arisen from improvements in systemic therapy. In the absence of effective systemic therapies, such local treatments were often considered futile given both the difficulty in eliminating all sites of identifiable metastatic disease as well as realities regarding the rapid natural history of uncontrolled tumor dissemination. However, with a higher likelihood of patients surviving longer after effective systemic therapy, even if not cured, the goal of the eradication of residual metastases via potent local therapies can be rationalized. However, this rationalization should be evidence-based so as to avoid harming patients for no established benefit. Although surgical metastectomy remains the most common and first-line standard among local therapies, nonsurgical alternatives, including thermal ablation and stereotactic body radiotherapy, have become increasingly popular because they are generally less invasive than surgery and have demonstrated considerable promise in eradicating macroscopic tumor. Rather than eliminating the need for local therapies, improvements in systemic therapies appear to be increasing the prudent utilization of modern local therapies in patients presenting with more advanced cancer.

Vein graft arterialization causes differential activation of mitogen-activated protein kinases.

OBJECTIVE: Vascular injury results in activation of the mitogen-activated protein kinases-extracellular-signal regulated kinases, c-jun N-terminal kinase, and p38(MAPK)-which have been implicated in cell proliferation, migration, and apoptosis. The goal of this study was to characterize mitogen-activated protein kinase activation in arterialized vein grafts. METHODS: Carotid artery bypass using reversed external jugular vein was performed in 29 dogs. Vein grafts were harvested after 30 minutes and 3, 8, and 24 hours, and 4, 7, 14, and 28 days. Contralateral external jugular vein and external jugular vein interposition vein-to-vein grafts were used as controls. Vein graft extracts were analyzed for extracellular-signal regulated kinases, c-jun N-terminal kinase, and p38(MAPK) activation. Proliferating cell nuclear antigen expression was investigated as a parameter of cell proliferation. Apoptosis was assessed by terminal deoxynucleotidyl transferase-mediated 2'-deoxyuridine 5'-triphosphate nick end labeling staining and intimal hyperplasia by morphometric examination of tissue sections. RESULTS: Significant intimal hyperplasia was observed at 28 days. Over the time points studied, vein graft arterialization resulted in bimodal activation of both extracellular-signal regulated kinase and p38(MAPK) (30 minutes through 3 hours; 4 days) but did not induce activation of c-jun N-terminal kinase. Proliferating cell nuclear antigen expression increased from days 1 through 28, and apoptosis increased between 8 and 24 hours. CONCLUSION: Vein graft arterialization induces bimodal activation of extracellular-signal regulated kinase and p38(MAPK); however, in contrast with what is described in arterial injury, it does not induce c-jun N-terminal kinase activation. These results provide the first comprehensive characterization of the mitogen-activated protein kinase signaling pathways activated in vein graft arterialization and identify mitogen-activated protein kinases as potential mediators of vein graft remodeling and subsequent intimal hyperplasia.

Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study.

BACKGROUND: Patients with severe atheromatous aortic disease (AAD) who undergo coronary artery bypass (CABG) have an increased risk of death and stroke. We hypothesized that in these high risk patients, off-pump coronary artery bypass (OPCAB) technique is associated with lower morbidity and mortality. METHODS AND RESULTS: Between June 1993 and January 2002, 5737 patients undergoing CABG had routine intra-operative TEE with 913 (15.9%) found to have severe AAD in the aortic arch or ascending aorta. Of these, 211 patients who underwent OPCAB were matched with 211 on-pump CABG patients by age, ejection fraction, history of stroke, cerebrovascular disease, diabetes, renal disease, nonelective operation, and previous cardiac surgery. Hospital mortality was 11.4% (24/211) for on-pump CABG and 3.8% (8/211) for OPCAB (P=0.003). Multivariate analysis revealed that increased mortality was associated with on-pump CABG (P=0.001), acute MI (P=0.03), number of grafts (P=0.01), age (P=0.01), history of stroke or cerebrovascular disease (P=0.04), CHF (P=0.02), and peripheral vascular disease (P=0.03). Multivariate analysis showed that OPCAB technique was associated with decreased stroke (P=0.05). Freedom from any complication was 78.7% for on-pump CABG and 91.9% for OPCAB (P<0.001). At 36 month follow-up multivariate analysis revealed that increased mortality was associated with age (P=0.001), previous MI (P=0.03), and renal disease (P=0.04), whereas increased survival was associated with increased number of grafts (P=0.001) and OPCAB (P=0.01). CONCLUSIONS: OPCAB surgery in patients with severe AAD is associated with lower risk of death, stroke and complications and improved mid-term survival. Routine intra-operative TEE allows identification of these patients and directs choice of appropriate surgical technique.

Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: impact on "off-pump" coronary artery bypass and perioperative stroke.

BACKGROUND: Patients with severe atheromatous aortic disease (AAD) undergoing coronary artery bypass grafting (CABG) have increased operative risks. The "off-pump" CABG (OPCAB) technique was evaluated in patients given the diagnosis of severe AAD by routine transesophageal echocardiography. METHODS: A total of 5737 patients underwent CABG, with 913 having transesophageal echocardiography findings of severe AAD. Of the patients with severe AAD, 678 (74.3%) had conventional CABG and 235 (25.7%) had OPCAB. RESULTS: Hospital mortality was 8.7% for conventional CABG and 5.1% for OPCAB (P =.08). Multivariate analysis revealed that increased mortality was significantly associated with acute myocardial infarction, conventional CABG, age, renal disease, history of stroke, and ejection fraction < 30%. Neurologic complications occurred in 6.3% of patients undergoing CABG and in 2.1% undergoing OPCAB (P =.01). Freedom from any complication was significantly greater with OPCAB. CONCLUSION: Routine intraoperative transesophageal echocardiography identifies patients with severe AAD. In these patients, OPCAB technique is associated with a lower risk of death, stroke, and all complications.

Evolving techniques for mitral valve reconstruction.

OBJECTIVE: To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA: MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS: Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS: Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS: These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques.