Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy.

INTRODUCTION: Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. METHODS: This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. RESULTS: Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak. CONCLUSIONS: Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma.

OBJECTIVE: Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision. METHODS: A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma. RESULTS: There was no association between tumor type and age group (P = .183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P < .001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P < .001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma. CONCLUSIONS: Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

Applications of Three-Dimensional Printing in Surgical Oncology.

A variety of three-dimensional (3D) printing techniques and materials facilitate the creation of customized models that promise to improve surgical procedures and patient outcomes. Three-dimensional-printed models allow patients, trainees, and experienced surgeons to explore anatomy through direct visualization and tactile feedback. Although 3D-printed models serve a range of purposes including preoperative planning, education, skills refinement, patient-specific intraprocedural guides, and implants, much work remains to decrease the turnaround time and cost of printing models, collect long-term effectiveness data, and refine regulatory oversight of 3D printing in medicine.

Performance of a rule-based semi-automated method to optimize chart abstraction for surveillance imaging among patients treated for non-small cell lung cancer.

BACKGROUND: We aim to develop and test performance of a semi-automated method (computerized query combined with manual review) for chart abstraction in the identification and characterization of surveillance radiology imaging for post-treatment non-small cell lung cancer patients. METHODS: A gold standard dataset consisting of 3011 radiology reports from 361 lung cancer patients treated at the Veterans Health Administration from 2008 to 2016 was manually created by an abstractor coding image type, image indication, and image findings. Computerized queries using a text search tool were performed to code reports. The primary endpoint of query performance was evaluated by sensitivity, positive predictive value (PPV), and F1 score. The secondary endpoint of efficiency compared semi-automated abstraction time to manual abstraction time using a separate dataset and the Wilcoxon rank-sum test. RESULTS: Query for image type demonstrated the highest sensitivity of 85%, PPV 95%, and F1 score 0.90. Query for image indication demonstrated sensitivity 72%, PPV 70%, and F1 score 0.71. The image findings queries ranged from sensitivity 75-85%, PPV 23-25%, and F1 score 0.36-0.37. Semi-automated abstraction with our best performing query (image type) improved abstraction times by 68% per patient compared to manual abstraction alone (from median 21.5 min (interquartile range 16.0) to 6.9 min (interquartile range 9.5), p < 0.005). CONCLUSIONS: Semi-automated abstraction using the best performing query of image type improved abstraction efficiency while preserving data accuracy. The computerized query acts as a pre-processing tool for manual abstraction by restricting effort to relevant images. Determining image indication and findings requires the addition of manual review for a semi-automatic abstraction approach in order to ensure data accuracy.

A brief overview of thoracic surgery in the United States.

The 331 million people of the United States are served by a complex and expensive healthcare system that accounts for nearly 18% of the country's gross domestic product. Over 90% of patients are insured by private or government-funded plans, but despite high coverage and unusually high healthcare spending, vast disparities exist within the United States population based on demographics in terms of diagnosis, treatment, and outcomes of disease. Thoracic surgeons in the United States are trained to treat patients with diseases of the chest in the operative and perioperative settings, and can accomplish this training through multiple highly competitive pathways. Thoracic surgeons perform an average of 135 operations each per year which address diseases of the lungs, trachea, esophagus, chest wall, mediastinum, and diaphragm. Video assisted thoracoscopic surgeries are the most commonly performed procedures, which are primarily completed to treat lung cancer. Lung cancer is the deadliest and second most prevalent malignancy in the United States, with over 200,000 new cases expected this year. In addition to encouragement of smoking cessation and more attention to air pollutants, increased access to lung cancer screening has significantly expedited diagnosis and reduced mortality from lung cancer in the last several years. Thoracic surgeons in the United States are tasked with treating common yet highly morbid diseases of the chest in a patient population that is diverse in terms of race, socioeconomic status, and healthcare insurance coverage. As the population ages and a shortage of thoracic surgeons looms, the importance of early diagnosis, skillful surgical management, and attention to the disparities that exist in our system cannot be overstated.

Polynitroxylated Pegylated Hemoglobin-A Novel, Small Volume Therapeutic for Traumatic Brain Injury Resuscitation: Comparison to Whole Blood and Dose Response Evaluation.

Resuscitation with polynitroxylated pegylated hemoglobin (PNPH), a pegylated bovine hemoglobin decorated with nitroxides, eliminated the need for fluid administration, reduced intracranial pressure (ICP) and brain edema, and produced neuroprotection in vitro and in vivo versus Lactated Ringer's solution (LR) in experimental traumatic brain injury (TBI) plus hemorrhagic shock (HS). We hypothesized that resuscitation with PNPH would improve acute physiology versus whole blood after TBI+HS and would be safe and effective across a wide dosage range. Anesthetized mice underwent controlled cortical impact and severe HS to mean arterial pressure (MAP) of 25-27 mm Hg for 35 min, then were resuscitated with PNPH, autologous whole blood, or LR. Markers of acute physiology, including mean arterial blood pressure (MAP), heart rate (HR), blood gases/chemistries, and brain oxygenation (PbtO2), were monitored for 90 min on room air followed by 15 min on 100% oxygen. In a second experiment, the protocol was repeated, except mice were resuscitated with PNPH with doses between 2 and 100 mL/kg. ICP and 24 h %-brain water were evaluated. PNPH-resuscitated mice had higher MAP and lower HR post-resuscitation versus blood or LR (p < 0.01). PNPH-resuscitated mice, versus those resuscitated with blood or LR, also had higher pH and lower serum potassium (p < 0.05). Blood-resuscitated mice, however, had higher PbtO2 versus those resuscitated with LR and PNPH, although PNPH had higher PbtO2 versus LR (p < 0.05). PNPH was well tolerated across the dosing range and dramatically reduced fluid requirements in all doses-even 2 or 5 mL/kg (p < 0.001). ICP was significantly lower in PNPH-treated mice for most doses tested versus in LR-treated mice, although %-brain water did not differ between groups. Resuscitation with PNPH, versus resuscitation with LR or blood, improved MAP, HR, and ICP, reduced acidosis and hyperkalemia, and was well tolerated and effective across a wide dosing range, supporting ongoing pre-clinical development of PNPH for TBI resuscitation.

Role of ß/δ101Gln in regulating the effect of temperature and allosteric effectors on oxygen affinity in woolly mammoth hemoglobin.

The oxygen affinity of woolly mammoth hemoglobin (rHb WM) is less affected by temperature change than that of Asian elephant hemoglobin (rHb AE) or human normal adult hemoglobin (Hb A). We report here a biochemical-biophysical study of Hb A, rHb AE, rHb WM, and three rHb WM mutants with amino acid substitutions at ß/δ101 (ß/δ101Gln→Glu, Lys, or Asp) plus a double and a triple mutant, designed to clarify the role of the ß/δ101 residue. The ß/δ101Gln residue is important for responding to allosteric effectors, such as phosphate, inositol hexaphosphate (IHP), and chloride. The rHb WM mutants studied generally have higher affinity for oxygen under various conditions of pH, temperature, and salt concentration, and in the presence or absence of organic phosphate, than do rHb WM, rHb AE, and Hb A. Titrations for the O2 affinity of these mutant rHbs as a function of chloride concentration indicate a lower heterotopic effect of this anion due to the replacement of ß/δ101Gln in rHb WM. The alkaline Bohr effect of rHb WM and its mutants is reduced by 20-50% compared to that of Hb A and is independent of changes in temperature, in contrast to what has been observed in the hemoglobins of most mammalian species, including human. The results of our study on the temperature dependence of the O2 affinity of rHb WM and its mutant rHbs illustrate the important role of ß/δ101Gln in regulating the functional properties of these hemoglobins.

Elevated body mass index increases early complications of surgical treatment of pelvic ring injuries.

OBJECTIVES: The purposes of this study were to evaluate the relationship between body mass index (BMI) and postoperative complications and to determine the incidence of reoperation after surgical treatment of pelvic ring injuries. SETTING: Three Level I trauma centers. PATIENTS/PARTICIPANTS: A retrospective review of 184 consecutive surgically treated pelvic ring injuries (Orthopaedic Trauma Association 61) was performed. Two patients died in the initial postoperative period, and the remaining 182 patients were followed for a minimum of 3 months. MAIN OUTCOME MEASUREMENTS: Complications that were evaluated included wound infection and dehiscence, loss of reduction, iatrogenic nerve injury, deep venous thrombosis, pneumonia, and the development of decubitus ulcers. Body mass index was calculated for each patient, and a BMI greater than 30 kg/m considered to be obese as defined by the National Institutes of Health. RESULTS: There were 132 males and 50 females with an average age of 36.4 years (range, 14-83 years). There were 48 (26%) patients with a BMI over 30 kg/m. Complications occurred in 46 of 182 patients (25.3%) with 26 occurring in the 48 patients with BMI greater than 30 kg/m (54.2% complication rate) and 20 occurring in the 134 patients with BMI less than 30 kg/m (14.9% complication rate). Complications included 20 infections (four superficial wound dehiscence and 16 deep), 23 losses of reduction, five deep vein thromboses, three pulmonary embolus, three pneumonia, two decubitus ulcers, and three iatrogenic nerve injuries. Reoperation was required in 29 of 182 (15.9%) patients with 16 (8.8%) irrigation and débridement, and 17 (9.3%) refixation procedures. All wound complications occurred after open exposures. Open exposures were performed for the anterior pelvic ring in 143 of 182 (78.6%) patients, the posterior pelvic ring in 64 of 182 (35.2%) patients, and percutaneous treatment of the posterior pelvic ring was performed in 80 of 182 (44.0%) patients. Logistic regression modeling analyzing BMI as a continuous variable found a relationship between increasing BMI and complication rate (P < 0.0001) and need for reoperation (P = 0.0013). Odds ratios analysis revealed that obese patients (BMI greater than 30 kg/m) were 6.87 (95% confidence interval, 3.25-14.49) times more likely to have a complication and 4.68 (95% confidence interval, 2.03-10.76) times more likely to undergo reoperation than patients with BMI less than 30 kg/m. CONCLUSIONS: Body mass index correlates with an increased rate of complications and reoperation after operative treatment of pelvic ring injuries.