Robotic Magnetic Sphincter Augmentation Device Removal.

Although most patients with reflux can be managed with medical therapy, some require surgical intervention to manage their disease. Newer technologies, such as magnetic sphincter augmentation (MSA), have been promoted as the replacement of fundoplication. However, as time has elapsed, our institution noticed the need for the removal of MSA devices. Although a few reports have described MSA device removals, we provide a deeper explanation of how to perform a robotic device removal. Our article describes the technical steps and includes a video to demonstrate how to complete the surgery robotically.

Report of a vagal paraganglioma at the cervicothoracic junction.

BACKGROUND: Vagus nerve paragangliomas are rare tumors, comprising 0.03% of head and neck neoplasms. These tumors are usually located cephalad to the hyoid bone, and there is only one previously reported case that arose from the lower third of the neck. METHODS: We describe the second reported case of a lower neck vagus nerve paraganglioma that was managed with a limited sternotomy for access and surgical removal. RESULTS: A 66-year-old male presented with a long-standing lesion of the cervicothoracic junction. CT, MRI, and Ga-68 DOTATATE PET/CT showed an avidly enhancing 5.2 × 4.2 × 11.5 cm mass extending from C6 to approximately T4 level. FNA confirmed the diagnosis. The patient underwent catheter angiography and embolization via direct puncture technique followed by excision of the mass via a combined transcervical and limited sternotomy approach. CONCLUSION: We describe an unusual case of vagal paraganglioma at the cervicothoracic junction with retrosternal extension requiring a sternotomy for surgical excision.

Effects of Smoking, Obesity, and Pulmonary Function on Home Oxygen Use after Curative Lung Cancer Surgery.

Rationale: Lung cancer surgical morbidity has been decreasing, increasing attention to quality-of-life measures. A chronic sequela of lung cancer surgery is the use of postoperative oxygen at home after discharge. Prospective studies are needed to identify risk predictors for home oxygen (HO2) use after curative lung cancer surgery. Objectives: To prospectively assess risk factors for postoperative oxygen use and postsurgical morbidity in patients undergoing curative lung cancer surgery. We hypothesized that obesity, poor preoperative pulmonary function, and smoking status would contribute to the risk of postoperative oxygen use. Methods: This study included patients undergoing surgery for a first primary non-small cell lung cancer at Mount Sinai from 2016 to 2020. Univariate, multivariable logistic regression analyses and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were assessed. Results: Of the 433 patients with diagnosed pathologic stage I non-small cell lung cancer, 63 (14.5%) were discharged with HO2. By using multivariable analyses, we found that the body mass index (BMI) (OR for a BMI of 25-30 kg/m2, 4.0; 95% CI, 1.6-11.2; OR for a BMI ⩾30 kg/m2, 6.1; 95% CI, 2.4-17.5) and the preoperative diffusing capacity of the lung for carbon monoxide (DlCO) (OR for a DlCO of <40%, 24.9; 95% CI, 3.6-234.1; OR for a DlCO of 40-59%, 3.1; 95% CI, 1.3-7.2) were significant independent risk factors associated with the risk of HO2 use after adjusting for other covariates. Although current smoking significantly increased the risk in the univariate analysis, it was no longer significant in the multivariable model. Conclusions: Obesity and the DlCO were significant as risk factors for oxygen use at home after discharge. These findings allow for identification of patients at risk of being discharged with HO2 after lung resection surgery.

Major modifications to minimize thoracic esophago-gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy.

BACKGROUND: The Ivor Lewis esophagectomy (ILE) remains the procedure of choice for localized middle or lower esophageal carcinoma. Nevertheless, anastomotic leak remains a common complication with rates from 3% to 25% and a stricture rate as high as 40%. The frequency of these complications suggests that the procedure itself may have inherent limitations including the use of potentially ischemic tissue for the esophagogastric anastomosis. We introduce a modified technique that reduces operative steps, preserves blood supply, and uses a modified esophagogastric anastomosis. METHODS: All consecutive patients undergoing ILE with the described modified technique were identified. An esophagram was performed on postoperative day six or seven. To ensure that all cases were identified, anastomotic leaks were defined as any radiographic evidence of contrast extravasation. RESULTS: A total of 110 patients underwent the modified esophagectomy with 2 anastomotic leaks (1.82%) and zero strictures. There was 1 late death but no early deaths (<30 or 90 days) or early re-admissions (<30 days). The average number of risk factors was 2.12, and 98 patients (90%) had at least 1 risk factor in their medical history. CONCLUSIONS: The modifications proposed simplify procedural steps, limit unnecessary dissection and introduce a technique that ends the practice of connecting ischemic tissue. We believe this technique contributes to surgical durability and reduces the rate of postoperative leak and eliminates stricture.

COVID-19 ventilator barotrauma management: less is more.

BACKGROUND: COVID-19 patients requiring mechanical ventilation may develop significant pneumomediastinum and sub-cutaneous emphysema without associated pneumothorax (SWAP). Prophylactic chest tube placement or sub-fascial "blowholes" are usually recommended to prevent tension pneumothorax and clinical decline. Risk of iatrogenic lung injury and release of virus into the environment is high. Incidence and conservative management data of such barotraumatic complications during the COVID-19 pandemic are lacking. METHODS: All patients with mediastinal air and SWAP evaluated by the department of Thoracic Surgery at the Mount Sinai Hospital between March 30 and April 10, 2020 were identified. All patients without pneumothorax were treated conservatively with daily chest x-ray and observation. Three patients had prophylactic chest tube placement prior to the study period without thoracic surgery consultation. RESULTS: There were 29 cases of mediastinal air with SWAP out of 171 COVID positive intubated patients (17.0%) who were treated conservatively. Patients were intubated for an average of 2.4 days before SWAP was identified. 12 patients (41%) had improvement or resolution without intervention. Two patients progressed to pneumothorax 3 and 8 days following initial presentation. Both had chest tubes placed without incident before there were any changes in oxygenation, hemodynamics, supportive medications, or ventilator settings. There were 3 patients who had percutaneous tubes placed before the study period all of whom had significant worsening of their sub-cutaneous air and air leak. CONCLUSIONS: Conservative management of massive sub-cutaneous emphysema without pneumothorax in COVID-19 patients is safe and limits viral exposure to healthcare workers. Placement of chest tubes is discouraged unless a definite sizable pneumothorax develops.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients.

BACKGROUND: Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited. METHODS: Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs. RESULTS: In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02). CONCLUSIONS: RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Second Primary Lung Cancers Demonstrate Similar Survival With Wedge Resection and Lobectomy.

BACKGROUND: Patients who have undergone curative surgery for stage I lung cancer require continued surveillance owing to the risk of a second primary lung cancer developing. Early diagnosis allows for prompt intervention. However, as in primary cancers, the role of wedge vs lobar resections remains controversial. METHODS: The Surveillance Epidemiology and End Results database was examined from 2004 to 2012 and all pathologically proven stage I lung cancer patients who underwent cancer-directed surgery were selected. Cases in which a second primary lung cancer developed 6 or more months after diagnosis of the first cancer were analyzed for survival after surgical treatment. RESULTS: Second primary lung cancer was identified in 625 patients, of whom 331 (53%) were diagnosed with stage I disease; 43.8% of patients underwent surgery alone, 30.9% received radiation alone, and 21.0% received neither surgery nor radiation. Of the patients who underwent surgery, 57.7% received wedge resection and 36.5% received a lobectomy. Surgical intervention was a positive predictor of survival-both wedge resection and lobectomy exhibited improved outcomes vs no surgery-but there was no statistically significant difference between the two surgical modalities. CONCLUSIONS: Wedge and lobar resections demonstrate similar survival for second primary lung cancers.

Oxygen Use After Lung Cancer Surgery.

BACKGROUND: There are no published reports on predictors of oxygen (O2) use after lung cancer surgery. The prospect of O2 use after lung cancer surgery may affect a patient's therapy choice. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare data set was queried to identify patients diagnosed with primary lung cancer (stage I/II) who underwent surgical resection from 1994 to 2010. Patients with a second resection within 6 months of their first and those with preoperative O2 use were excluded. Multivariable logistic regression was performed to evaluate the odds ratios and 95% confidence intervals of O2 use (defined as being billed for home O2) after discharge for lung cancer surgery. RESULTS: Of 21,245 eligible patients from 1994 to 2010, 3,255 (15.3%) were billed for O2 use in the first month of discharge. Of these, 13.7% (447 of 3,255) stopped using within 1 month, and 1.47% died. By 6 months, an additional 6.7% died, and 46.27% (1,384 of 2,991) were still alive and using O2. Discharge on O2 was associated with higher odds of death within 6 months (odds ratio, 1.35; 95% confidence interval, 1.17 to 1.55). The significant, independent risk factors for O2 use at discharge were procedure, sex, race, histology, pulmonary comorbidities, obesity, length of stay, pulmonary complications, and discharge mode. CONCLUSIONS: Home O2 use after lung cancer surgery comprises a sizable portion of this population and is correlated with death in the first 6 months. Various predictors significantly increased the risk of O2 use at discharge. However, 49.3% of those originally discharged on O2 were alive and off O2 at 6 months.

Outcomes for Thoracoscopy Versus Thoracotomy Not Just Technique Dependent: A Study of 9,787 Patients.

BACKGROUND: Studies reporting the benefits of video-assisted thoracoscopic surgery (VATS) lung cancer resection over thoracotomy have been subject to selection bias. We evaluated patient and hospital characteristics associated with type of surgery and the independent effect of VATS on outcomes. METHODS: The Statewide Planning and Research Cooperative System of New York State database was queried to identify all lung cancer patients undergoing lobectomy or sublobar resection between 2007 and 2012. Multivariable logistic regression was performed to identify patient (age, sex, race, comorbidities, year, and insurance) and hospital (urban, teaching, and total lung surgery volume) cofactors associated with surgical technique and propensity scores were used to evaluate whether technique was independently associated with complications or in-hospital mortality. RESULTS: There were 5,505 lobectomy and 4,282 sublobar resection patients, with 2,318 (42%) and 2,416 (56%) undergoing VATS, respectively. For lobectomy, VATS was associated with being female, lower comorbidity index, private insurance, older age, surgery in recent year, nonteaching hospital, and higher annual lung surgery volume. For sublobar resection, VATS was associated with black race, lower comorbidity index, Medicaid or other insurance, surgery in recent year, rural hospital, and higher annual lung surgery volume. Complication rate was significantly lower for VATS lobectomy and not sublobar resection, whereas in-hospital mortality was lower for VATS in both resection groups. CONCLUSIONS: Numerous patient- and hospital-related variables that affect morbidity and mortality also affect whether a patient undergoes VATS or open lung resection. Studies evaluating VATS must account more accurately for selection bias and adjust for these confounders.

Outcomes after Video-assisted Thoracoscopic Lobectomy versus Open Lobectomy for Early-Stage Lung Cancer in Older Adults.

RATIONALE: Video-assisted thoracoscopic surgery (VATS) and open lobectomy are both standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC) because of equivalent long-term survival. OBJECTIVES: To evaluate whether the improved perioperative outcomes associated with VATS lobectomy are explained by surgeon characteristics, including case volume and specialty training. METHODS: We analyzed the Surveillance, Epidemiology, and End Results-Medicare-linked registry to identify stage I-II NSCLC in patients above 65 years of age. We used a propensity score model to adjust for differences in patient characteristics undergoing VATS versus open lobectomy. Perioperative complications, extended length of stay, and perioperative mortality among patients were compared after adjustment for surgeon's volume and specialty using linear mixed models. We compared survival using a Cox model with robust standard errors. RESULTS: We identified 9,508 patients in the registry who underwent lobectomy for early-stage NSCLC. VATS lobectomies were more commonly performed by high-volume surgeons (P < 0.001) and thoracic surgeons (P = 0.01). VATS lobectomy was associated with decreased adjusted odds of cardiovascular complications (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.47-0.90), thromboembolic complications (OR = 0.47; 95% CI = 0.38-0.58), extrapulmonary infections (OR = 0.75; 95% CI = 0.61-0.94), extended length of stay (OR = 0.47; 95% CI = 0.40-0.56), and perioperative mortality (OR = 0.33; 95% CI = 0.23-0.48) even after controlling for differences in surgeon volume and specialty. Long-term survival was equivalent for VATS and open lobectomy (hazard ratio = 0.95; 95% CI = 0.85-1.08) after controlling for patient and tumor characteristics, surgeon volume, and specialization. CONCLUSIONS: VATS lobectomy for NSCLC is associated with better postoperative outcomes, but similar long-term survival, compared with open lobectomy among older adults, even after controlling for surgeon experience.

Personal and hospital factors associated with limited surgical resection for lung cancer, in-hospital mortality and complications in New York State.

BACKGROUND AND OBJECTIVES: Early stage lung cancer is generally treated with surgical resection. The objective of the study was to identify patient and hospital characteristics associated with the type of lung cancer surgical approach utilized in New York State (NYS), and to assess in-hospital adverse events. METHODS: A total of 33 960 lung cancer patients who underwent limited resection (LR) or lobectomy (L) were selected from the NYS Statewide Planning and Research Cooperative System database (1995-2012). RESULTS: LR patients were more likely to be older (adjusted odds ratio ORadj and [95% confidence interval]: 1.01 [1.01-1.02]), female (ORadj : 1.11 [1.06-1.16]), Black (ORadj : 1.17 [1.08-1.27]), with comorbidities (ORadj : 1.08 [1.03-1.14]), and treated in more recent years than L patients. Length of stay and complications were significantly less after LR than L (ORadj : 0.56 [0.53-0.58] and 0.65 [0.62-0.69]); in-hospital mortality was similar (ORadj : 0.93 [0.81-1.07]), and was positively associated with age and urgent/emergency admission, but inversely associated with female gender, private insurance, recent admission year, and surgery volume. CONCLUSIONS: There was a growing trend toward LR, which was more likely to be performed in older patients with comorbidities. In-hospital outcomes were better after LR than L, and were affected by patient and hospital characteristics.

Computed Tomography Screening for Lung Cancer: Mediastinal Lymph Node Resection in Stage IA Nonsmall Cell Lung Cancer Manifesting as Subsolid and Solid Nodules.

OBJECTIVE: To compare long-term survival rates of patients with first, primary, clinical stage IA nonsmall cell lung cancer from a large cohort undergoing computed tomography screening with and without mediastinal lymph node resection (MLNR) under an Institutional Review Board-approved common protocol from 1992 to 2014. BACKGROUND: Assessing survival differences of patients with and without MLNR manifesting as solid and subsolid nodules. METHODS: Long-term Kaplan-Meier (K-M) survival rates for those with and without MLNR were compared and Cox regression analyses were used to adjust for demographic, computed tomography, and surgical covariates. RESULTS: The long-term K-M rates for 462 with and 145 without MLNR was 92% versus 96% (P = 0.19), respectively. For 203 patients with a subsolid nodule, 151 with and 52 without MLNR, the rate was 100%. For the 404 patients with a solid nodule, 311 with and 93 without MLNR, the rate was 87% versus 94% (P = 0.24) and Cox regression showed no statistically significant difference (P = 0.28) when adjusted for all covariates. Risk of dying increased significantly with increasing decades of age (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.4-3.8), centrally located tumor (HR 2.5, 95% CI 1.2-5.2), tumor size 21 to 30 mm (HR 2.7, 95% CI 1.2-6.0), and invasion beyond the lung stroma (HR 3.0, 95% CI 1.4-6.1). For the 346 patients with MLNR, tumor size was 20 mm or less; K-M rates for the 269 patients with and 169 patients without MLNR were also not significantly different (HR 2.1, P = 0.24). CONCLUSIONS: It is not mandatory to perform MLNR when screen-diagnosed nonsmall cell lung cancer manifests as a subsolid nodule.

Survival after Sublobar Resection for Early-Stage Lung Cancer: Methodological Obstacles in Comparing the Efficacy to Lobectomy.

INTRODUCTION: Surgery is the treatment of choice for early-stage lung cancer (LC). Although lobectomy (L) is the historic standard treatment, the issue of whether long-term outcomes of sublobar resection (SL) are comparable is still under debate. The objective of this study was to perform a review of the literature on 5-year survival rates after SL compared to L for patients with early-stage LC. METHODS: A priori inclusion criteria were as follows: (1) observational studies, (2) L compared to SL for early-stage LC, (3) radiographic staging by computed tomography scan, and (4) 5-year survival reported. A Medline search through January 2015 resulted in 31 studies representing 23 distinct datasets. The absolute difference in 5-year survival was calculated and plotted for each study. RESULTS: L was performed in 4564 patients and SL in 2287 patients. Of 19 studies reporting the reason for SL, 11 indicated that SL was performed because of comorbidities or impaired cardiopulmonary function. Four studies showed no difference in 5-year survival, 13 favored L, and six favored SL. One propensity score study favored L and the other favored SL. Of 20 studies reporting recurrence rate, 11 favored L and nine favored SL. CONCLUSIONS: Studies comparing 5-year survival rates of SL to L are sufficiently heterogeneous to prevent carrying out traditional meta-analysis. SL survival is often similar to L when adjustments are made for age, comorbidities, or impaired cardiopulmonary function. New approaches are needed for the comparison of L to SL.

Determinants of Survival in Malignant Pleural Mesothelioma: A Surveillance, Epidemiology, and End Results (SEER) Study of 14,228 Patients.

INTRODUCTION: Left untreated, malignant pleural mesothelioma (MPM) is associated with uniformly poor prognosis. Better survival has been reported with surgery-based multimodality therapy, but to date, no trial has demonstrated survival benefit of surgery over other therapies. We evaluated whether cancer-directed surgery influenced survival independently from other predictors in a large population-based dataset. METHODS: The SEER database was explored from 1973 to 2009 to identify all cases of pathologically-proven MPM. Age, sex, race, year of diagnosis, histology stage, cancer-directed surgery, radiation, and vital status were analyzed. The association between prognostic factors and survival was estimated using Cox regression and propensity matched analysis. RESULTS: There were 14,228 patients with pathologic diagnosis of MPM. On multivariable analysis, female gender, younger age, early stage, and treatment with surgery were independent predictors of longer survival. In comparison to no treatment, surgery alone was associated with significant improvement in survival [adjusted hazard ratio (adj HR) 0.64 (0.61-0.67)], but not radiation [adj HR 1.15 (1.08-1.23)]. Surgery and radiation combined had similar survival as surgery alone [adj HR 0.69 (0.64-0.76)]. Results were similar when cases diagnosed between 1973 and 1999 were compared to cases diagnosed between 2000 and 2009. CONCLUSIONS: Despite developments in surgical and radiation techniques, the prognosis for MPM patients has not improved over the past 4 decades. Cancer-directed surgery is independently associated with better survival, suggesting that multimodal surgery-based therapy can benefit these patients. Further research in adjuvant treatment is necessary to improve prognosis in this challenging disease.

Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance.

OBJECTIVE: Controversies regarding the safety, morbidity, and mortality of thoracoscopic lobectomy have prevented the widespread acceptance of the procedure. This series analyzed the safety, pain, analgesic use, and discharge disposition in patients who underwent thoracoscopic lobectomy and segmentectomy at a single institution. METHODS: We collected data from 153 consecutive patients who underwent thoracoscopic (video-assisted thoracic surgery) lobectomy and assessed the perioperative outcomes, postoperative pain, and chemotherapy course. A total of 111 of 127 patients with lung cancer had stage I non-small cell lung cancer. The operative technique required 2 ports and an access incision (5-8 cm), individual hilar ligation, and lymph node dissection performed without rib-spreading devices. RESULTS: There were 9 major complications (6%), including 1 perioperative death (0.7%). Conversion to thoracotomy occurred in 14 patients (9.2%). Blood transfusion was required in 11 patients (7%). The median chest tube time was 3 days, and the length of hospital stay was 4 days; 94.4% of patients went home at the time of discharge, and 5.6% of patients required a rehabilitation facility. At a median postsurgical follow-up time of 2 weeks, the mean postoperative pain score was 0.6 (0-3), 73% of patients did not use narcotics for pain control, and 47% of patients did not use any pain medication. Of patients receiving chemotherapy (N = 26), 73% completed a full course on schedule and 85% received all intended cycles. CONCLUSION: Thoracoscopic (video-assisted thoracic surgery) lobectomy can be performed safely. Discharge independence and low pain estimates in the early postoperative period suggest that this approach may be beneficial. Furthermore, there is a trend toward improved tolerance of chemotherapy.

Is occult lymph node disease in colorectal cancer patients clinically significant? A review of the relevant literature.

The clinical significance of micrometastasis of colorectal cancer (CRC) to regional lymph nodes remains controversial. In this review, we analyze publications that have evaluated the clinical significance of occult lymph node metastasis in CRC. An extensive literature search identified 19 publications that evaluated the clinical significance of micrometastatic CRC by various methods, including immunohistochemistry (IHC; n = 13) and reverse transcription-polymerase chain reaction (RT-PCR, n = 6). These studies were reviewed for methodology and findings. Significant limitations in methodology were identified, including inconsistent histological definitions of micrometastatic disease, poor sampling because of an inadequate number of lymph nodes or number of sections per lymph node analyzed, lack of conformity with respect to IHC antibody or RT-PCR marker, and inadequate power because of small sample size. Micrometastatic lymph node metastasis identified by RT-PCR was consistently found to be prognostically significant, but this was not true of micrometastatic disease identified by IHC. RT-PCR analysis of lymph nodes with specific markers can help identify pN0 (pathological-negative lymph node) CRC patients at increased risk for recurrence. The identification of occult disease by IHC techniques may also ultimately prove to be associated with worse outcome, but a number of inadequately powered studies have concluded conversely.

Evaluation of efficacy of an ultrasonic scalpel for pulmonary vascular ligation in an animal model.

OBJECTIVE: Dissection to accommodate bulky stapling devices may cause injury to pulmonary arteries in thoracoscopic lobectomies. The Harmonic Ace (Ethicon Endo-Surgery, Inc; Cincinnati, Ohio), a small ultrasonic scalpel used in systemic vessels, was tested on pulmonary vessels in pigs. METHODS: Nine pigs were assigned 1- or 6-week survival. Lobectomies were performed using the device to divide and ligate pulmonary vessels. Vessel diameter was measured, and ligation outcome was recorded. Necropsies were then performed. RESULTS: Permanent ligation occurred in 76% of arteries and 92% of veins. At the highest power setting, the instrument showed no failure in arteries 5 mm or less and veins 7 mm or less. Necropsies revealed no evidence of postoperative bleeding. Histopathologic analysis revealed acute coagulation necrosis at 1 week. By 6 weeks, the vessel stumps displayed features consistent with normal wound healing. CONCLUSIONS: This device reliably divides pulmonary vessels 4 mm and smaller, typically encountered in pig lobectomies. Higher power settings and operator experience may increase effectiveness. Further testing is necessary to delineate the device's limitations before potential use in human pulmonary vasculature.

Complete surgical resection of a 40-cm leiomyosarcoma of the large bowel mesentery.

INTRODUCTION: Leiomyosarcoma of the large bowel mesentery is a rare entity and characteristically behaves in an aggressive fashion. Surgical resection is the mainstay of treatment and offers both symptomatic and therapeutic benefit. CASE: We describe the case of a 55-year-old woman who presented with weight loss, increasing abdominal girth and a large solid inhomogenous mass within the abdomen and pelvis demonstrated on a computed tomography (CT) scan. The patient underwent an exploratory laparotomy and extensive tumor debulking procedure with complete resection of her tumor. Final pathology revealed leiomyosarcoma of the large bowel mesentery. The patient has chosen not to receive adjuvant therapy. CONCLUSIONS: Leiomyosarcoma of the large bowel mesentery often presents as an advanced lesion making surgical resection a challenging and potentially morbid procedure. Although surgical resection may be faced with significant morbidity, maximum surgical effort with complete resection offers the best overall outcome for patients with this disease.