Thoracoabdominal resection of giant malignant esophageal solitary fibrous tumor.

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm. It usually originates from the parietal pleura. SFT originating from the esophagus is exceedingly rare and even more so as a malignancy. We report a 57-year-old patient with a malignant 18 cm SFT of the esophagus that was treated with esophagectomy through a left thoracoabdominal incision. We discuss his surgical and oncologic management.

Nightly Preoperative Huddle Email Improves Perioperative Efficiency.

BACKGROUND: Our institution created a nightly "Huddle" email for all staff involved in patient care, detailing the next day's cases. This study evaluated the impact of the Huddle email on perioperative efficiency and identified factors associated with operating room delays. METHODS: A total of 1080 first start, open, nonemergent cardiac operations were stratified as Pre-Huddle (January 2013-June 2015) or Huddle (July 2015-January 2017). Scheduled start-to-in-room time (delay time), in-room-to-incision time, and total minutes utilized were analyzed. On-time starts were defined as a delay time of 0 minutes, and long delays were defined as delay time of more than 15 minutes. Long delays were compared with other cases based on preoperative factors. Multivariate regression identified independent predictors of delay time. RESULTS: The analysis included 643 Pre-Huddle and 437 Huddle cases. After Huddle implementation, delay time decreased by 2 minutes (9 minutes Pre-Huddle vs 7 minutes Huddle, P < .001). However, time to incision increased (70 minutes vs 73 minutes, P = .002), as did minutes utilized (373 minutes vs 394 minutes, P = .002) in the Huddle era. On-time entry increased 46% (5.0% to 9.2%, P = .007), and long delay decreased 26% (33.3% vs 24.3%, P = .002). Long delay was associated with urgent cases (58.2% vs 28.6%, P < .001), non-Society of Thoracic Surgeons Predicted Risk of Mortality cases (46.9% vs 34.1%, P < .001), and less surgeon experience (7 years vs 9 years, P < .001). Delay time was independently predicted by urgent status (+10.17 minutes), surgeon experience (-0.15 min/y), lung disease (+5.43 minutes), and non-Society of Thoracic Surgeons Predicted Risk of Mortality (+5.44 minutes) on multivariate regression. CONCLUSIONS: Implementation of the Huddle improved delay time, on-time entry, and long delay. Strategies focused on optimizing perioperative care are beneficial for multidisciplinary teams.

First 100 consecutive robotic inguinal hernia repairs at a Veterans Affairs hospital.

The utilization of robotics in general surgery has increased significantly including usage in the Veterans Affairs (VA) system. We implemented a robotic inguinal hernia repair (RIHR) program in our VA hospital and report on initial experience with safety and outcomes. The first 100 consecutive RIHR at a VA hospital were reviewed and compared against the results of contemporaneous open inguinal hernia repair (OIHR). Data were collected for operative characteristics, surgical complications and pain related outcomes. Overall, operative times for OIHR were less than RIHR (83.7 vs. 109.7 min, p < 0.0001); however, there was no difference in operative time for bilateral repairs (121.5 vs. 121.9 min, p = ns). Complication rates were similar between the groups. RIHR patients had less pain at POD 1 than OIHR patients (p = 0.05). RIHR were less likely to have multiple post-op visits for pain than OIHR patients (p = 0.003). RIHR can be implemented in the VA system with acceptable surgical outcomes. RIHR may be associated with less post-operative pain in the early post-operative period.

Left atrial thrombi following tranexamic acid in a bleeding trauma patient-A word of caution.

We describe the case of a bleeding trauma patient who received tranexamic acid (TXA) during air transport who subsequently developed multiple intra-cardiac thrombi. The administration of TXA during transport may be associated with this unusual presentation.

Multispecialty involvement in the management of type B aortic dissections in the endovascular era-Implications for training cardiothoracic residents.

PURPOSE: Involvement of qualified specialists with proficiency in endovascular therapies has created flux regarding the role of cardiothoracic surgeons, vascular surgeons, and other catheter-skilled specialists in the management of type B aortic dissections. We used manuscript authorship trends and recent match data in order to study how multi-specialty involvement in treating aortic dissections has changed in the endovascular era. METHODS: A PubMed review of published literature between 1998 and 2015 was performed with "aortic dissection" in the title. Case studies and entries with incomplete author or identifying information were excluded. Author number, specialty affiliation, and treatment focus were recorded. Available residency match data were obtained from the National Resident Matching Program (NRMP). RESULTS: Cardiothoracic surgeons represented 38.5% (10/23) of the authors for papers with an endovascular focus in 1998 compared with 27.7% (59/213) in 2015. Vascular surgeons represented 19.2% (5/23) and 37.1% (79/213) of authors in 1998 and 2015, respectively. Radiologists accounted for 30.4% (7/23) of authorship in 1998 and 8.9% (19/213) in 2015. NRMP match data revealed a 10.6% decrease in thoracic surgery matches from 2004 to 2015, while vascular surgery and interventional radiology increased by 74.7% and 191.1%, respectively. CONCLUSIONS: Endovascular technologies have resulted in significant changes as to which specialties manage complicated type B aortic dissections. Vascular surgeons, with both open and extensive endovascular training are optimally positioned to assume a major role in the care of aortic dissection patients. Continued emphasis on endovascular training and multispecialty collaboration is essential for cardiothoracic surgeons in the endovascular era.

Anterior Leaflet Augmentation With CorMatrix Porcine Extracellular Matrix in Twenty-Five Patients: Unexpected Patch Failures and Histologic Analysis.

BACKGROUND: This study reported on the treatment of Carpentier type IIIa and type IIIb mitral regurgitation (MR) with a large patch anterior mitral valve leaflet augmentation technique using CorMatrix (CorMatrix Cardiovascular Inc, Alpharetta, GA) extracellular matrix (ECM). METHODS: A single-site chart review was conducted on patients who underwent anterior leaflet augmentation performed with the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) or through a median sternotomy. Only patients who had anterior leaflet augmentation with porcine intestine ECM or autologous pericardium were included. Follow-up echocardiography was performed on all patients. Histologic specimens were available on ECM patches from a subset of patients who required reoperation. RESULTS: Between August 2011 and April 2014, 44 patients (mean age, 62.6 ± 12.2 years) underwent anterior leaflet augmentation with either porcine intestinal ECM or autologous pericardium at the Temple University Hospital in Philadelphia. Two (4%) late deaths occurred, one in each group. One patient who underwent ECM augmentation died of non-cardiac-related causes 7 months after discharge as a result of complications of chronic renal failure. The second late death occurred 5 months after discharge because of complications of a stroke in a patient in the pericardial augmentation group. Eight (32%) of the patients with ECM had recurrence of severe MR on echocardiography at an average time of 201 ± 98 days. Seven (28%) patients required reoperation because of failure of the ECM patch including perforation (4%), excessive patch dilation (20%), and suture line dehiscence (4%). In contrast, none of the patients with pericardial augmentation developed severe MR or required operation. Statistical analysis of the patients with ECM augmentation demonstrated no correlation of the following: age; sex; comorbid conditions such as diabetes, chronic obstructive pulmonary disease, and hypertension; left ventricular ejection fraction; surgical approach; annuloplasty size; or type of MR with patch failure. A lower body mass index was the only factor associated with recurrent severe regurgitation on univariate analysis (p = 0.039). Histologic study of the four available explants demonstrated intense inflammation without evidence of host integration. The remaining 15 (60%) patients had normal mitral leaflet structure and function on follow-up echocardiograms out to 12 months. CONCLUSIONS: For type III MR, a large anterior leaflet patch technique with porcine ECM was associated with a 32% recurrence rate of severe MR related directly to patch failure. Further research and development should be performed on the use of ECM materials with a goal to decrease the failure rate experienced in this study.

Novel Annular and Subvalvular Enlargement in Congenital Mitral Valve Replacement.

Reparative procedures are not always feasible in congenitally abnormal mitral valves. Mechanical prosthesis has been accepted as the choice for valve replacement in the pediatric population. This report describes a case of congenital mitral valve disease requiring mitral valve replacement. The infant's mitral valve annulus was not amenable to placement of the smallest available mechanical prosthesis. The approach used here for annular and subvalvular enlargement facilitated implantation of a larger prosthesis for congenital mitral valve replacement. Five-year outcomes in a single patient may indicate broader applicability and avoidance of patient-prosthesis mismatch.

Adaptation to altitude as a vehicle for experiential learning of physiology by university undergraduates.

In this article, an experiential learning activity is described in which 19 university undergraduates made experimental observations on each other to explore physiological adaptations to high altitude. Following 2 wk of didactic sessions and baseline data collection at sea level, the group ascended to a research station at 12,500-ft elevation. Here, teams of three to four students measured the maximal rate of oxygen uptake, cognitive function, hand and foot volume changes, reticulocyte count and hematocrit, urinary pH and 24-h urine volume, athletic performance, and nocturnal blood oxygen saturation. Their data allowed the students to quantify the effect of altitude on the oxygen cascade and to demonstrate the following altitude-related changes: 1) impaired performance on selected cognitive function tests, 2) mild peripheral edema, 3) rapid reticulocytosis, 4) urinary alkalinization and diuresis, 5) impaired aerobic but not anaerobic exercise performance, 6) inverse relationship between blood oxygen saturation and resting heart rate, and 7) regular periodic nocturnal oxygen desaturation events accompanied by heart rate accelerations. The students learned and applied basic statistical techniques to analyze their data, and each team summarized its results in the format of a scientific paper. The students were uniformly enthusiastic about the use of self-directed experimentation to explore the physiology of altitude adaptation and felt that they learned more from this course format than a control group of students felt that they learned from a physiology course taught by the same instructor in the standard classroom/laboratory format.