Scoring Tool to Predict Need for Early Video-Assisted Thoracoscopic Surgery (VATS) After Pediatric Trauma.

BACKGROUND: No widely used stratification tool exists to predict which pediatric trauma patients may require a video-assisted thoracoscopic surgery (VATS). We sought to develop a novel VATS-In-Pediatrics (VIP) score to predict the need for early VATS (within 72 h of admission) for pediatric trauma patients. METHODS: The pediatric 2017-2020 Trauma Quality Improvement Program database was used and divided into two sets (derivation set using 2017-2019 data and validation set using 2020 data). First, multiple logistic regression models were created to determine the risk of early VATS for patients ≤ 17 years old. Second, the weighted average and relative impact of each independent predictor were used to derive a VIP score. We then validated the score using the area under the receiver operating characteristic (AROC) curve. RESULTS: From 218,628 patients in the derivation set, 2183 (1.0%) underwent early VATS. A total of 8 independent predictors of VATS were identified, and the VIP score was derived with scores ranging from 0 to 9. The AROC for this was 0.91. The VATS rate increased steadily from 12.5 to 32% then 60.5% at scores of 3, 4, and 6, respectively. In the validation set, from 70,316 patients, 887 (1.3%) underwent VATS, and the AROC was 0.91. CONCLUSIONS: VIP is a novel and validated scoring tool to predict the need for early VATS in pediatric trauma. This tool can potentially help hospital systems prepare for pediatric patients at high risk for requiring VATS during their first 72 h of admission. Future prospective research is needed to evaluate VIP as a tool that can improve clinical outcomes.

A Systematic Review of Short-Term Outcomes of Minimally Invasive Thoracoscopic Surgery for Lung Cancer after Neoadjuvant Systemic Therapy.

BACKGROUND: Minimally invasive surgeries for non-small cell lung cancers (NSCLCs) such as video-assisted thoracoscopic surgeries (VATSs) and robotic-assisted thoracoscopic surgeries (RATSs) have become standard of care for patients needing surgical resection in early stages. The role for neoadjuvant systemic therapy has increased with patients receiving neoadjuvant systemic chemotherapy and immunotherapy. However, there has been some equipoise over the intraoperative and overall outcomes for these patients. Here, we review the current data regarding outcomes of patients undergoing minimally invasive thoracic surgical resection after systemic chemotherapy, immunotherapy, or both. METHODS: A systematic literature review of randomized controlled trials and observational studies presenting data on patients with NSCLC that underwent neoadjuvant systemic therapy followed by minimally invasive surgery was performed assessing complications, conversion rates, and lymph node yield. RESULTS: Our search strategy and review of references resulted in 239 publications to screen with 88 full texts assessed and 21 studies included in our final review. VATS had a statistically significant higher lymph node yield in five studies. The reported conversion rates ranged from 0 to 54%. Dense adhesions, bleeding, and difficult anatomy were the most common reported reasons for conversion to open surgeries. The most common complications between both groups were prolonged air leak, arrythmia, and pneumonia. VATS was found to have significantly fewer complications in three papers. CONCLUSIONS: The current literature supports VATS as safe and feasible for patients with NSCLC after neoadjuvant systemic treatment. Surgeons should remain prepared to convert to open surgeries in those patients with dense adhesions and bleeding risk.

Elastofibroma Dorsi: Case Series of a Rare Chest Wall Pseudotumor.

BACKGROUND: Elastofibroma dorsi (EFD) is a pseudotumor of the thoracic wall that can be difficult to diagnose due to its rarity. Prompt recognition can limit unnecessary workup and expedite treatment. This study retrospectively analyzed patients with a diagnosis of EFD, discussing clinical presentations and surgical outcomes. METHODS: This is an IRB-approved single-center retrospective study of all patients with a diagnosis of elastofibroma at our institution between 2000 and 2022. RESULTS: Ten patients were identified to have a pathologic diagnosis of EFD since 2000, with half presenting in the last 5 years. Our cohort had an average age of 56.8 years and was 50% female. The average age of male subjects was younger than females, 49.6-64.0 years, respectively (p = 0.10). Eighty percent (8/10) of patients had unilateral EFDs and symptoms lasted 27.1 months on average prior to diagnosis. Surgical resection was performed on 66.67% (8/12) of masses, with 87.5% (7/8) of patients who underwent surgery reporting complete resolution of their symptoms and none reporting recurrence. CONCLUSIONS: Although EFD is a rare pseudotumor, its incidence may be increasing. As such, surgeons should be aware of the typical clinical presentation; specifically, a slow growing, predominantly unilateral, painful, subscapular mass with an inhomogeneous pattern on imaging. Originally thought to predominantly affect elderly women, our study shows that younger men may be at risk as well. If patients present with EFD, complete surgical resection should be performed to achieve favorable outcomes and resolution of symptoms.

Dawn of a New Normal: Resident and Faculty Attitudes in Adopting Virtual Conferences and Education.

BACKGROUND: The COVID-19 pandemic has dramatically changed education in medical residencies with the need to transition to a virtual format. The objective of this study is to assess the adoption of a virtual format for grand rounds, M&M, and education of the surgical department. METHOD: A 25 question online survey was developed using Qualtrics and distributed to faculty and resident physicians in the Department of Surgery from March to April 2021. RESULTS: Fifty four out of 79 potential respondents (68%) completed the survey. Twenty-seven out of 54 (50%) respondents stated they were more likely to be participating in another activity most of the time or always. During to in-person conferences, 20/54 (37%) of participants reported being more distracted by other activities. Forty-two out of 54 (78%) participants strongly agree that virtual conferences are more flexible with their schedule and saves them travel time. All of the faculty want conferences to continue virtually (with or without an in-person component) citing virtual conferences are more flexible with their schedule and saves travel time. However, 4/26 (15%) of residents responded not wanting to continue virtual education citing work distractions and not truly having protected time. CONCLUSION: As the Coronavirus 2019 (COVID-19) pandemic is continuing with new variants, the virtual education and conference format is necessary. There is overwhelming support from both residents and faculty in favor of the virtual conference format due to flexibility, ease, and convenience. However, care must be taken to make sure that resident education time is truly protected.

Long-term assessment of efficacy with a novel Thoracic Survivorship Program for patients with lung cancer.

OBJECTIVE: We developed a novel, nurse practitioner-run Thoracic Survivorship Program to aid in long-term follow-up. Patients with non-small cell lung cancer who were disease-free at least 1 year after resection could be referred to the Thoracic Survivorship Program by their surgeon. Our objectives were to summarize follow-up compliance and assess long-term outcomes between Thoracic Survivorship Program enrollment and non-Thoracic Survivorship Program. METHODS: Patients who underwent R0 resection for stages I to IIIA between 2006 and 2016 were stratified by enrollment in Thoracic Survivorship Program versus surgeon only follow-up (non-Thoracic Survivorship Program). Follow-up included 6-month chest computed tomography scans for 2 years and then annually. Lack of follow-up compliance was defined by 2 or more consecutive delayed annual computed tomography scans/visits ± 90 days. Relationships between Thoracic Survivorship Program and second primary non--small cell lung cancers, extrathoracic cancers, and survival were quantified using multivariable Cox proportional hazards regression with time-varying covariate reflecting timing of enrollment. RESULTS: A total of 1162 of 3940 patients (29.5%) were enrolled in the Thoracic Survivorship Program. The median time to enrollment was 2.3 years; 3279 of 3940 (83%) had complete computed tomography scan data, and 60 of 3279 (1.8%) had 2 or more delayed scans; 323 of 9082 (3.6%) non-Thoracic Survivorship Program visits were noncompliant versus 132 of 4823 (2.7%) of Thoracic Survivorship Program visits (P = .009); 136 of 1146 Thoracic Survivorship Program patients developed second primary non-small cell lung cancer, and 69 of 1123 developed extrathoracic cancer, whereas 322 of 2794 of non-Thoracic Survivorship Program patients developed second primary non-small cell lung cancer and 225 of 2817 patients developed extrathoracic cancer. In multivariable analyses, Thoracic Survivorship Program enrollment was associated with improved disease-free survival (hazard ratio, 0.57; 95% confidence interval, 0.48-0.67; P < .001). CONCLUSIONS: Our novel nurse practitioner-run Thoracic Survivorship Program is associated with high patient compliance and outcomes not different from those seen with physician-based follow-up. These results have important implications for health care resource allocation and costs.

How Effective Is Neoadjuvant Therapy Followed by Surgery for Pathologic Single-Station N2 Non-Small Cell Lung Cancer?

The optimal treatment strategy for pathologic single-station N2 (pN2a1) non-small cell lung cancer (NSCLC)-surgery first followed by adjuvant treatment (SF) or neoadjuvant therapy followed by surgery (NS)-remains unclear. We compared disease-free survival (DFS) and overall survival (OS) after NS versus SF for pN2a1 NSCLC. We retrospectively identified patients with pN2a1 NSCLC resected between 2000 and 2018. Patients in the SF group had cN0 disease and were treated with surgery before adjuvant chemotherapy; patients in the NS group had known preoperative nodal disease, cN2 disease, and were treated with neoadjuvant therapy before surgery. The matching-weights procedure was applied to generate a cohort with similar characteristics between groups. DFS and OS were calculated using the Kaplan-Meier approach and compared between groups using weighted log-rank test and Cox proportional hazards models. We identified 227 patients with pN2a1 disease: 121 treated with SF and 106 with NS. After the matching-weights procedure, 5- and 10-year DFS were 45% and 27% for SF versus 26% and 21% for NS (log-rank P = 0.056; hazard ratio [HR], 1.61; 95% confidence interval [CI], 0.98-2.65); 5- and 10-year OS were 49% and 30% for SF versus 43% and 20% for NS (log-rank P = 0.428; HR, 1.24; 95% CI, 0.67-2.28). SF and NS for pN2a1 NSCLC resulted in similar survival. A study comparing SF for known preresectional pN2a1 with occult pN2a1 disease could be a next step. Further investigation of SF for known N2a1 versus occult pN2a1 disease could power a clinical trial focused on N2a NSCLC.

Postoperative surgical trainee opioid prescribing practices (POST-OPP): A national survey.

BACKGROUND: Increasing opioid-related deaths have heightened focus on combating the opioid epidemic. The impact of surgical trainees on opioid-related deaths is unclear, and there is little data examining the association between trainee pain management education and opioid prescribing practices. METHODS: An anonymous, online survey was distributed to members of the Resident and Associate Society of the American College of Surgeons. The survey covered five themes: education and knowledge, prescribing practices, clinical case scenarios, policy, and beliefs and attitudes. Linear mixed models were used to evaluate the influence of respondent characteristics on reported morphine milligram equivalents (MME) prescribed for common general surgery clinical scenarios. RESULTS: Of 427 respondents, 54 percent indicated receiving training in postoperative pain management during medical school and 66 percent during residency. Only 35 percent agreed that they had received adequate training in prescribing opioids. There was a significant association between undergoing formal pain management training in medical school and prescribing fewer MME for common outpatient general surgery scenarios (94 ± 15.2 vs 108 ± 15.0; p = 0.003). Similarly, formal pain management training in residency was associated with prescribing fewer MME in the survey scenarios (92.6 ± 15.2 vs 109 ± 15.2; p = 0.002). CONCLUSION: In this survey, nearly two-thirds of surgical residents felt that they were inadequately trained in opioid pre-scribing. Our findings additionally suggest that improving education may result in increased resident comfort with man-aging surgical pain, potentially leading to more responsible opioid prescribing. Further work will facilitate residency pro-grams' development of educational curricula for opioid prescribing best practices.

Correction to: Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

The following disclaimer is missing from the original article.

Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

BACKGROUND: Projections based on regulations curtailing asbestos use in the USA suggest that peak incidence of pleural mesothelioma would occur between 2000 and 2005 and then decline. We analyzed the National Cancer Database (NCDB) to assess current trends in disease incidence, patient demographics, cancer treatment, and survival. METHODS: The NCDB was queried to identify patients diagnosed with pleural mesothelioma from 2004 through 2014. Clinical and pathologic characteristics, treatments, and survival were analyzed. Risk factors for death were identified by multivariable Cox regression. RESULTS: A total of 20,988 patients with pleural mesothelioma were reported to the NCDB. The number of cases per year increased from 1783 to 1961, accounting for roughly 0.3% of all reported cancers each year. The proportion of elderly patients increased from 75 to 80%, but distribution by sex remained constant (20% female). The proportion of patients undergoing treatment increased from 34 to 54%. One-year survival increased from 37 to 47% and 3-year survival from 9 to 15% (p < 0.001). Factors associated with improved survival included younger age, female sex, epithelioid histology, treatment in an academic center, health insurance, higher income, and multimodality therapy. CONCLUSIONS: The annual incidence of mesothelioma has not declined this century and remains stable. Reporting of histologic and clinical staging has improved. National trends suggest that survival is slowly increasing despite an aging cohort. Multimodal therapy and treatment at academic centers are modifiable risk factors associated with improved survival.

The Bigger Picture: Picking the Right Soap Box-Is it Possible to Connect with Different Audience Targets (Practitioners and Patients) from the Same Platform?

The use of Internet and social media has skyrocketed in the past decade. It did not take long until physicians realized that they could use social media as a tool for communication with patients and colleagues. Since then use of social media has exploded and the information that has become available for physicians and their patients is remarkable. In addition, because of the immediacy of the platform, messages that are incorrect or not desired can be rapidly promoted, whether deliberately or accidentally. To obtain the best use of social media, the right platform should be chosen, and this varies depending on the group one is trying to reach, and the message or visibility desired. In this article, we review the variety of options available to users.

Bariatric surgery may reduce the risk of Alzheimer's diseases through GLP-1 mediated neuroprotective effects.

Obesity and diabetes are associated with deficits in multiple neurocognitive domains and increased risk for dementia. Over the last two decades, there has been a significant increase in bariatric and metabolic surgery worldwide, driven by rising intertwined pandemics of obesity and diabetes, along with improvement in surgical techniques. Patients undergoing bariatric surgery achieve a significant decrease in their excess weight and a multitude of sequela associated with obesity, diabetes, and metabolic syndrome. Glucagon-like peptide 1 (GLP-1) is an intestinal peptide that has been implicated as one of the weight loss-independent mechanisms in how bariatric surgery affects type 2 diabetes. GLP-1 improves insulin secretion, inhibits apoptosis and induce pancreatic islet neogenesis, promotes satiety, and can regulate heart rate and blood pressure. Moreover, numerous studies have demonstrated potential neuroprotective and neurotrophic effects of GLP-1. Increased GLP-1 activity has been shown to increase cortical activity, promote neuronal growth, and inhibit neuronal degeneration. Specifically, in experimental studies on Alzheimer's disease, GLP-1 decreases amyloid deposition and neurofibrillary tangles. Furthermore, recent studies have also suggested that GLP-1 based therapies, new class of antidiabetic drugs, have favorable effects on neurodegenerative disorders such as Alzheimer's disease. We present a hypothesis that bariatric surgery can help delay or even prevent the onset of Alzheimer's disease in long-term by increasing the levels of GLP-1. This hypothesis has a potential for many studies from basic science projects to large population studies to fully understand the neurological and cognitive consequences of bariatric surgery and associated rise in GLP-1.

A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy.

OBJECTIVES: Limited data exist comparing robotic and open approaches to pancreaticoduodenectomy (PD). We performed a multicenter comparison of perioperative outcomes of robotic PD (RPD) and open PD (OPD). METHODS: Perioperative data for patients who underwent postlearning curve PD at 8 centers (8/2011-1/2015) were assessed. Univariate analyses of clinicopathologic and treatment factors were performed, and multivariable models were constructed to determine associations of operative approach (RPD or OPD) with perioperative outcomes. RESULTS: Of the 1028 patients, 211 (20.5%) underwent RPD (4.7% conversions) and 817 (79.5%) underwent OPD. As compared with OPD, RPD patients had higher body mass index, rates of prior abdominal surgery, and softer pancreatic remnants, whereas OPD patients had a higher percentage of pancreatic ductal adenocarcinoma cases, and greater proportion of nondilated (<3 mm) pancreatic ducts. On multivariable analysis, as compared with OPD, RPD was associated with longer operative times [mean difference = 75.4 minutes, 95% confidence interval (CI) 17.5-133.3, P = 0.01], reduced blood loss (mean difference = -181 mL, 95% CI -355-(-7.7), P = 0.04) and reductions in major complications (odds ratio = 0.64, 95% CI 0.47-0.85, P = 0.003). No associations were demonstrated between operative approach and 90-day mortality, clinically relevant postoperative pancreatic fistula and wound infection, length of stay, or 90-day readmission. In the subset of 522 (51%) pancreatic ductal adenocarcinomas, operative approach was not a significant independent predictor of margin status or suboptimal lymphadenectomy (<12 lymph nodes harvested). CONCLUSIONS: Postlearning curve RPD can be performed with similar perioperative outcomes achieved with OPD. Further studies of cost, quality of life, and long-term oncologic outcomes are needed.

The Natural History of Operable Non-Small Cell Lung Cancer in the National Cancer Database.

BACKGROUND: The survival of untreated non-small cell lung cancer (NSCLC), or the natural history, is an important perspective for patients considering resection for NSCLC. The National Cancer Database (NCDB) allows untreated NSCLC patients who were recommended to undergo surgical resection (ie, "operable") to be identified. The survival of untreated NSCLC patients in the NCDB was studied to determine the natural history of operable NSCLC. METHODS: The NCDB was queried for untreated clinical stage I to IIIA NSCLC patients diagnosed between 2003 and 2009. The natural history cohort was defined as patients who were recommended to undergo resection but went untreated. RESULTS: We identified 1,693 untreated patients with operable NSCLC. The median survival for clinical stage I, II, and IIIA was 16.6, 9.4, and 8.4 months, respectively. The 5-year Kaplan-Meier estimates of survival for clinical stage I, II, and IIIA NSCLC were 10.1%, 7.3%, and 4.9%, respectively. At each stage (I to IIIA), the survival of untreated operable NSCLC patients was superior to that of untreated NSCLC patients not recommended to undergo resection (nonoperable, p < 0.001). A multivariable Cox regression model identified increasing age, male gender, white (vs black) race, increasing comorbidity, squamous cell or large cell histology, and increasing stage as predictors of decreased survival. CONCLUSIONS: The natural history of operable NSCLC, although poor, varies with clinical stage and is superior to that of nonoperable NSCLC.

A model for predicting prolonged length of stay in patients undergoing anatomical lung resection: a National Surgical Quality Improvement Program (NSQIP) database study.

OBJECTIVES: There are currently no studies that have specifically delineated the risk factors for a prolonged length of hospitalization in patients undergoing anatomical lung resection. Knowing these risk factors is important in terms of risk stratification and improving outcomes in the high-risk population. The goal of this study was to identify risk factors associated with a prolonged length of stay (≥14 days) in patients undergoing an anatomical lung resection and to further create a model for predicting the probability of a prolonged length of stay in these patients. METHODS: The NSQIP database (2005-2013) was culled for data on 45 distinct preoperative, intraoperative and postoperative variables among patients undergoing anatomical pulmonary resections. Univariate and multivariate logistic regression analyses were used to determine variables that contributed to a prolonged length of stay. A scoring system was created based on these results and applied to internal and external (a single institution database) validation groups to test for the adequacy of the model through the comparison of receiver operating characteristic curves. RESULTS: Fifteen factors were found to be significant for prolonged length of stay; six were preoperative (age >70 years [P < 0.0001], functional status-dependent [P = 0.0020], chronic obstructive pulmonary disease [P < 0.0001], serum sodium <135 mmol/l [P = 0.0200], ASA Class 3 [P = 0.0070] and ASA Class 4 or 5 [P = 0.0010]), one was intraoperative (open thoracotomy [P < 0.0001]) and eight were postoperative (pneumonia [P < 0.0001], unplanned reintubation [P < 0.0001], prolonged mechanical ventilation [P < 0.0001], urinary tract infection [P < 0.0001], stroke [P = 0.0020], transfusion [P = 0.0010], deep vein thrombosis/thrombophlebitis [P < 0.0001] and return to the operating room [P < 0.0001]). CONCLUSIONS: A simple model for predicting the probability of a prolonged length of stay in patients undergoing anatomical lung resection has been successfully created. This model can allow for better risk stratification of patients preoperatively based on certain existing comorbidities, and can help to predict the impact the development of various postoperative complications will have on overall patient outcomes.

Sigmoid volvulus in a patient with mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS): a rare occurrence.

Mitochondrial diseases are rare and devastating, with a wide spectrum of clinical presentations and systemic symptoms. The majority of the published literature focuses on the neuromuscular manifestations and genetic components of this mitochondrial cytopathy, however, cardiac, renal, endocrine and gastrointestinal manifestations may also be present. The authors report a case detailing a 56-year-old woman's final hospitalisation from the gastrointestinal sequelae of mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) (Co Q10 deficiency variant). She presented with abdominal pain and distension associated with lactic acidosis, and was shown on imaging to have a colon perforation. This resulted in emergent surgery at which a necrotic colon secondary to a sigmoid colon was identified. Following four subsequent operations, and the development of multiorgan failure, care was eventually withdrawn. Practitioners of patients with MELAS should be cognisant of the rare but devastating gastrointestinal consequences of mitochondrial diseases.

Cardiovascular Complications Following Thoracic Surgery.

Cardiovascular events after thoracic surgery can result in increased morbidity, mortality, length of stay, and increased overall cost. The prevention of postoperative cardiovascular complications is an area of intense study, and the body of evidence guiding clinicians continues to grow. Early diagnosis and management of cardiovascular events can minimize the consequences of these complications.

Timing of heparin and thrombus formation in donor lungs after cardiac death.

BACKGROUND: Heparin is routinely administered to brain-dead donors before cardiac arrest, although it is not universally allowed for donation after cardiac death (DCD) donors due to concerns that death may be hastened. The lack of heparin may lead to thrombosis and compromised graft function. We evaluated the impact of timing of heparin administration and thrombi formation in a DCD pig model. METHODS: Eight domestic adult pigs were administered systemic heparin (30,000 IU): four prior to cardiac arrest through intravenous injection (prearrest heparin) and four after cardiac arrest via injection into the right atrium followed by open cardiac massage (postarrest heparin). Pigs were euthanized with potassium chloride and a minimum of 5 minutes of cardiac silence allowed before organ procurement. Lungs were flushed with antegrade and retrograde Perfadex, and pulmonary preservation solution effluent was evaluated for gross thrombi. Organs were fixed in formalin, sagittally sectioned, and evaluated by a pulmonary pathologist blinded to treatment. RESULTS: Antegrade and retrograde flushes demonstrated no significant thrombi. Gross pathologic evaluation revealed no occlusive central thrombi. Scant peripheral thrombi were detected in both treatment groups. No microscopic thrombi were noted in either treatment group. CONCLUSIONS: Delayed heparin administration after cardiac death does not affect thrombus formation in an animal model of lung procurement after cardiac death. Concern about clinically significant thrombosis occurring when heparin is not given before cardiac arrest appears unfounded. These findings suggest that DCD lungs can be used regardless of antemortem heparin administration.