Routine chest radiography after thoracostomy tube removal and during postoperative follow-up is not necessary after lung resection.

OBJECTIVES: The need for routine chest radiography following chest tube removal after elective pulmonary resection may be unnecessary in most patients. The purpose of this study was to determine the safety of eliminating routine chest radiography in these patients. METHODS: Patients who underwent elective pulmonary resection, excluding pneumonectomy, for benign or malignant indications between 2007 and 2013 were reviewed. Patients with in-hospital mortality or without routine follow-up were excluded. During this interval, our practice transitioned from ordering routine chest radiography after chest tube removal and at the first postoperative clinic visit to obtaining imaging based on symptomatology. The primary outcome was changes in management from results of chest radiography obtained routinely versus for symptoms. Characteristics and outcomes were compared using the Student t test and chi-square analyses. RESULTS: A total of 322 patients met inclusion criteria. Ninety-three patients underwent a routine same-day post-pull chest radiography, and 229 patients did not. Thirty-three patients (14.4%) in the nonroutine chest radiography cohort received imaging for symptoms, in whom 8 (24.2%) resulted in management changes. Only 3.2% of routine post-pull chest radiography resulted in management changes versus 3.5% of unplanned chest radiography with no adverse outcomes (P = .905). At outpatient postoperative follow-up, 146 patients received routine chest radiography; none resulted in a change in management. Of the 176 patients who did not have planned chest radiography at follow-up, 12 (6.8%) underwent chest radiography for symptoms. Two of these patients required readmission and chest tube reinsertion. CONCLUSIONS: Reserving imaging for patients with symptoms after chest tube removal and follow-up after elective lung resections resulted in a higher percentage of meaningful changes in clinical management.

Historical Perspective on Lung Cancer Screening.

Lung cancer represents a large burden on society with a staggering incidence and mortality rate that has steadily increased until recently. The impetus to design an effective screening program for the deadliest cancer in the United States and worldwide began in 1950. It has taken more than 50 years of numerous clinical trials and continued persistence to arrive at the development of modern-day screening program. As the program continues to grow, it is important for clinicians to understand its evolution, track outcomes, and continually assess the impact and bias of screening on the medical, social, and economic systems.

Impact of Environmental Exposures on Lung Cancer in Patients Who Never Smoked.

BACKGROUND: Despite the rising incidence of lung cancer in patients who never smoked, environmental risk factors such as ambient air pollution in this group are poorly described. Our objective was to identify the relationship of environmental exposures with lung cancer in patients who never smoked. METHODS: A prospectively collected database was reviewed for all patients with non-small cell lung carcinoma (NSCLC) who underwent resection from 2006 to 2021. Environmental exposures were estimated using the geocoded home address of patients. Logistic regression was used to determine the association of clinical and environmental variables with smoking status. Kaplan-Meier and Cox proportional hazards analyses were used to assess survival. RESULTS: A total of 665 patients underwent resection for NSCLC, of which 67 (10.1%) were patients who never smoked and 598 (89.9%) were current/former smokers. Patients who never smoked were more likely of white race (p = 0.001) and had well-differentiated tumors with carcinoid or adenocarcinoma histology (p < 0.001). Environmental exposures were similar between groups, but patients who never smoked had less community material deprivation (p = 0.002) measured by household income, education, health insurance, and vacancies. They had improved overall survival (p = 0.012) but equivalent cancer recurrence (p = 0.818) as those who smoked. In univariable Cox analyses, fine particulate matter (HR: 1.447 [95% CI 1.197-1.750], p < 0.001), distance to nearest major roadway (HR: 1.067 [1.024-1.111], p = 0.002), and greenspace (HR: 0.253 [0.087-0.737], p = 0.012) were associated with overall survival in patients who never smoked. CONCLUSIONS: Lung cancer patients who never smoked have unique clinical and pathologic characteristics, including higher socioeconomic status. Interventions to reduce environmental exposures may improve lung cancer survival in this population.

A decade of surgical outcomes in a structured lung cancer screening program.

OBJECTIVE: Lung cancer screening can decrease mortality. The majority of screen-detected cancers are early stage and undergo surgical resection. However, there are little data regarding the outcomes of surgical treatment outside of clinical trials. The purpose of this study was to compare the outcomes of curative resection for screen-detected lung cancers with nonscreened, incidentally detected cancers at an institution with a structured screening program. METHODS: Patients undergoing lung cancer curative resection from January 2012 to June 2021 were identified from a prospective database. Baseline patient characteristics, tumor characteristics, and outcomes were compared between cancer detected from screening and cancer detected incidentally. RESULTS: There were 199 patients in the incidental group and 82 patients in the screened group. Mean follow-up was 33.3 ± 25 months. The screened group had more African Americans (P = .04), a higher incidence of emphysema (P = .02), less prior cancers (P < .01), and more pack-years smoked (P < .01). The screened group had a smaller size (1.74 vs 2.31 cm, P < .01); however, pathologic stage was similar, with the majority being stage I. Postoperative morbidity, 30-day mortality, and overall and recurrence-free survival were similar between groups. Only 48.7% of the incidental group met current US Preventative Services Task Force screening criteria (age 50-80 years, ≥20 pack-year smoking history). CONCLUSIONS: Screen-detected lung cancers have excellent postoperative and long-term outcomes with curative resection, similar to incidentally detected cancers. A large portion of incidentally detected lung cancers do not meet current screening guidelines, which is an opportunity for further refinement of eligibility.

Lung cancer screening utilization rate varies based on patient, provider, and hospital factors.

OBJECTIVE: Low-dose computed tomography has been proven to reduce mortality, yet utilization remains low. The purpose of this study is to identify factors that impact the utilization of lung cancer screening. METHODS: We performed a retrospective review of our institution's primary care network from November 2012 to June 2022 to identify patients who were eligible for lung cancer screening. Eligible patients were 55 to 80 years of age and current or former smokers with at least a 30 pack-year history. Analyses were performed on the screened populations and patients who met eligibility criteria but were not screened. RESULTS: A total of 35,279 patients in our primary care network were current/former smokers aged 55 to 80 years. A total of 6731 patients (19%) had a 30 pack-year or more cigarette history, and 11,602 patients (33%) had an unknown pack-year history. A total of 1218 patients received low-dose computed tomography. The utilization rate of low-dose computed tomography was 18%. The utilization rate was significantly lower (9%) if patients with unknown pack-year history were included (P < .001). The utilization rates between primary care clinic locations were significantly different (range, 18% vs 41%, P < .05). Utilization of low-dose computed tomography on multivariate analysis was associated with Black race, former smoker, chronic obstructive pulmonary disease, bronchitis, family history of lung cancer, and number of primary care visits (all P < .05). CONCLUSIONS: Lung cancer screening utilization rates are low and vary significantly on the basis of patient comorbidities, family history of lung cancer, primary care clinic location, and accurate documentation of pack-year cigarette history. The development of programs to address patient, provider, and hospital-level factors is needed to ensure appropriate lung cancer screening.

Safety and efficacy of an implantable device for management of gastroesophageal reflux in lung transplant recipients.

BACKGROUND: Magnetic sphincter augmentation (MSA) is a promising minimally invasive surgical technique for management of gastroesophageal reflux disease (GERD); however, device implantation after transplantation has not been studied and may be concerning in these immunosuppressed patients. We explored the safety of the LINX Reflux Management System (MSA device) for management of GERD following lung transplantation (LTx). METHODS: Lung transplant recipients who underwent LINX implantation at our institution between 2017 and 2019 were followed prospectively in the Reflux Following Lung Transplantation and Associated Treatment Registry. Ambulatory pH testing and acid-suppressing medication use were compared before and after LINX implantation. One-year outcomes and change in pulmonary function were compared between matched LINX and fundoplication groups. RESULTS: Of 17 patients who underwent post-lung transplant LINX implantation, 8 (47.1%) agreed to undergo post-LINX pH testing. Three/eight (37.5%) patients achieved normal esophageal acid exposure time; 14 (82.4%) remained on acid-suppressing medication at one-year under the direction of their transplant teams. One-year patient survival and change in pulmonary function were similar between groups. LINX patients experienced more early side effects. CONCLUSIONS: Use of the LINX MSA device in a cohort of lung transplant recipients at our institution was associated with similar short-term safety compared to traditional fundoplication, however assessment of efficacy was limited. Further investigation is needed to characterize the long-term efficacy of LINX implantation after LTx.

Minimally invasive surgery in the management of resectable thymoma: a retrospective analysis from the National Cancer Database.

BACKGROUND: Thymomas are relatively uncommon tumors traditionally resected via open sternotomy. Despite the appeal of minimally invasive techniques, concerns persist regarding their oncologic efficacy. We hypothesized that minimally-invasive thymectomies for resectable thymomas are oncologically safe when compared to open thymectomy. METHODS: The National Cancer Database (NCDB) was queried for patients with thymoma undergoing resection as the first mode of treatment between 2010-2015. Patient demographics, tumor characteristics and perioperative outcomes were examined for each approach (robotic, thoracoscopic, or open). The primary endpoints were rates of complete (R0) resection and need for adjuvant radiotherapy. Chi-square and Student's t-test and logistic regression were used for analysis. RESULTS: A total of 2,312 patients were identified. The utilization of myocardial infarction (MI) surgery increased during the study period (robotic: 7.6% to 19.5%; thoracoscopic: 9.3% to 18.4%, both P<0.0001). Median tumor size was higher and mediastinal invasion was more common in open thymectomies. R0 resection was more common in robotic and adjuvant radiotherapy was less frequent in thoracoscopic thymectomies. In multivariate analysis absence of mediastinal invasion (P<0.0001) was the only prognostic factor for R0 resection. Positive margins, mediastinal invasion (both P<0.0001) and younger age (P<0.01) were the only predictors of the need for adjuvant radiotherapy. CONCLUSIONS: Utilization of MI approaches for resectable thymoma has increased from 2010 to 2015. After adjusting for tumor size and mediastinal invasion, minimally-invasive thymectomy was not associated with lower R0 resection rates or increased use of adjuvant radiotherapy. MI thymectomy for resectable thymoma is oncologically equivalent to open thymectomy.

VATS and Minimally Invasive Resection in Early-Stage NSCLC.

Lung carcinoma widely affects men and women in the sixth and seventh decades of life. Thorough workup with radiographic imaging, pathologic diagnosis, and cardiopulmonary functional assessment is key to successful treatment. Accurate staging is essential for both assessing prognosis and directing therapy. Early-stage lung cancer is most often treated with anatomic lobectomy; locally advanced cancers may require induction or adjuvant therapies. Any nonnodal metastases will require definitive systemic therapy. Traditionally, surgery was performed with a posterolateral thoracotomy incision, division of the hilar vessels, removal of affected lung parenchyma, and a complete mediastinal and hilar lymph node dissection for accurate pathologic staging. In recent years, however, video-assisted thoracoscopic (VATS) or other minimally invasive approaches have emerged as the standard of care for early-stage disease. Compared with standard thoracotomy, VATS lobectomy offers improved postoperative outcomes as well as potential survival benefit. Thoracoscopic lobectomy is also cost-effective. This article focuses on the technique, outcomes, adaptation, and evolution of thoracoscopic lobectomy and other minimally invasive techniques in the treatment of lung cancer.

Meningeal Foam Cells and Ependymal Cells in Axolotl Spinal Cord Regeneration.

A previously unreported population of foam cells (foamy macrophages) accumulates in the invasive fibrotic meninges during gap regeneration of transected adult Axolotl spinal cord (salamander Ambystoma mexicanum) and may act beneficially. Multinucleated giant cells (MNGCs) also occurred in the fibrotic meninges. Actin-label localization and transmission electron microscopy showed characteristic foam cell and MNGC podosome and ruffled border-containing sealing ring structures involved in substratum attachment, with characteristic intermediate filament accumulations surrounding nuclei. These cells co-localized with regenerating cord ependymal cell (ependymoglial) outgrowth. Phase contrast-bright droplets labeled with Oil Red O, DiI, and DyRect polar lipid live cell label showed accumulated foamy macrophages to be heavily lipid-laden, while reactive ependymoglia contained smaller lipid droplets. Both cell types contained both neutral and polar lipids in lipid droplets. Foamy macrophages and ependymoglia expressed the lipid scavenger receptor CD36 (fatty acid translocase) and the co-transporter toll-like receptor-4 (TLR4). Competitive inhibitor treatment using the modified fatty acid Sulfo-N-succinimidyl Oleate verified the role of the lipid scavenger receptor CD36 in lipid uptake studies in vitro. Fluoromyelin staining showed both cell types took up myelin fragments in situ during the regeneration process. Foam cells took up DiI-Ox-LDL and DiI-myelin fragments in vitro while ependymoglia took up only DiI-myelin in vitro. Both cell types expressed the cysteine proteinase cathepsin K, with foam cells sequestering cathepsin K within the sealing ring adjacent to the culture substratum. The two cell types act as sinks for Ox-LDL and myelin fragments within the lesion site, with foamy macrophages showing more Ox-LDL uptake activity. Cathepsin K activity and cellular localization suggested that foamy macrophages digest ECM within reactive meninges, while ependymal cells act from within the spinal cord tissue during outgrowth into the lesion site, acting in complementary fashion. Small MNGCs also expressed lipid transporters and showed cathepsin K activity. Comparison of 3H-glucosamine uptake in ependymal cells and foam cells showed that only ependymal cells produce glycosaminoglycan and proteoglycan-containing ECM, while the cathepsin studies showed both cell types remove ECM. Interaction of foam cells and ependymoglia in vitro supported the dispersion of ependymal outgrowth associated with tissue reconstruction in Axolotl spinal cord regeneration.

Case Volume-to-Outcome Relationship in Minimally Invasive Esophagogastrectomy.

BACKGROUND: Outcomes after open esophagogastrectomy (OE) have been shown to depend on institution case volume. We aim to determine whether a similar relationship exists for minimally invasive esophagogastrectomy (MIE). METHODS: Patients who had OE or MIE (excluding robotic procedures) between 2010 and 2013 in the National Cancer Database were included. Outcomes included 30-day and 90-day mortality, length of stay, hospital readmission, margin positivity, and number of lymph nodes harvested. Logistic and linear regression were used to adjust for possible confounders including age, sex, tumor size, Charlson score, induction therapy, and type of institution (academic versus community based). RESULTS: We identified 2371 patients in the MIE group and 6285 patients in the OE group. In multivariate analysis, high case volume was an independent predictor for lower 30-day mortality and 90-day mortality, shorter length of stay, and higher rate of negative-margin resection in OE (P < .001) but not in MIE. After quartile ranking of institutions based on volume, MIE outcomes were found to be better in institutions in the highest volume quartile compared with those in the lowest (P < .001). CONCLUSIONS: In this dataset, MIE postoperative outcomes, unlike OE postoperative outcomes, did not correlate with hospital case volume. Volume-outcome relationships may be affected by surgical approach. The effect of case volume on long-term outcomes after MIE warrants further study.

Left Transthoracic Approach for Magnetic Sphincter Augmentation Device LINX Implantation.

Magnetic sphincter augmentation with the LINX Reflux Management System (Torax Medical, St. Paul, MN) is a recently introduced surgical option with comparable therapeutic efficacy for medically refractory gastroesophageal reflux disease. An appropriately sized LINX device is usually placed around the gastroesophageal junction through a laparoscopic approach. In general, redo abdominal surgeries are technically challenging, with a higher risk of associated morbidity. This highlights the need to obtain feasible alternative access to place the LINX device for certain patient populations. In this case series, we described 2 patients who underwent LINX device implantation through left thoracotomy because of previous abdominal surgeries that prohibited a transabdominal approach.

Operative time in esophagectomy: Does it affect outcomes?

BACKGROUND: The effect of operative duration on postoperative outcomes of esophagectomy is not well understood. The relationship between operative duration and postoperative complications was explored. METHODS: Esophagectomies with gastric reconstruction performed between 2010 and 2015 were queried from the National Surgical Quality Improvement Program. Linear and multivariate regression analyses were used to determine if operative duration correlated with outcomes independent of comorbidities. Subset analysis was performed by the type of esophagectomy. RESULTS: There were 5,098 patients with a median age and operative time of 64 years and 353 minutes, respectively. In the transhiatal group, longer operative times correlated with increased rates of pneumonia, prolonged intubation, unplanned reintubation, septic shock, unplanned reoperation, duration of stay, and mortality. For Ivor-Lewis esophagectomy, there were similar correlations with postoperative complications but not mortality. With the McKeown approach, there were no correlations between operative duration and postoperative outcomes. CONCLUSION: Prolonged operative time has an independent adverse impact on postoperative morbidity, which varies by surgical approach. We have identified unique cut points in the operative time for transhiatal (333 minutes) and Ivor-Lewis esophagectomy (422 minutes), which can be used as a prognostic marker for postoperative outcomes as well as a quality metric in well-selected patients.

Musashi and Plasticity of Xenopus and Axolotl Spinal Cord Ependymal Cells.

The differentiated state of spinal cord ependymal cells in regeneration-competent amphibians varies between a constitutively active state in what is essentially a developing organism, the tadpole of the frog Xenopus laevis, and a quiescent, activatable state in a slowly growing adult salamander Ambystoma mexicanum, the Axolotl. Ependymal cells are epithelial in intact spinal cord of all vertebrates. After transection, body region ependymal epithelium in both Xenopus and the Axolotl disorganizes for regenerative outgrowth (gap replacement). Injury-reactive ependymal cells serve as a stem/progenitor cell population in regeneration and reconstruct the central canal. Expression patterns of mRNA and protein for the stem/progenitor cell-maintenance Notch signaling pathway mRNA-binding protein Musashi (msi) change with life stage and regeneration competence. Msi-1 is missing (immunohistochemistry), or at very low levels (polymerase chain reaction, PCR), in both intact regeneration-competent adult Axolotl cord and intact non-regeneration-competent Xenopus tadpole (Nieuwkoop and Faber stage 62+, NF 62+). The critical correlation for successful regeneration is msi-1 expression/upregulation after injury in the ependymal outgrowth and stump-region ependymal cells. msi-1 and msi-2 isoforms were cloned for the Axolotl as well as previously unknown isoforms of Xenopus msi-2. Intact Xenopus spinal cord ependymal cells show a loss of msi-1 expression between regeneration-competent (NF 50-53) and non-regenerating stages (NF 62+) and in post-metamorphosis froglets, while msi-2 displays a lower molecular weight isoform in non-regenerating cord. In the Axolotl, embryos and juveniles maintain Msi-1 expression in the intact cord. In the adult Axolotl, Msi-1 is absent, but upregulates after injury. Msi-2 levels are more variable among Axolotl life stages: rising between late tailbud embryos and juveniles and decreasing in adult cord. Cultures of regeneration-competent Xenopus tadpole cord and injury-responsive adult Axolotl cord ependymal cells showed an identical growth factor response. Epidermal growth factor (EGF) maintains mesenchymal outgrowth in vitro, the cells are proliferative and maintain msi-1 expression. Non-regeneration competent Xenopus ependymal cells, NF 62+, failed to attach or grow well in EGF+ medium. Ependymal Msi-1 expression in vivo and in vitro is a strong indicator of regeneration competence in the amphibian spinal cord.

Clinical Characteristics of Patients Experiencing Pathologic Complete Response Following Neoadjuvant Therapy for Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma.

OBJECTIVES: The purpose of this study is to describe clinical characteristics and outcomes of patients with borderline resectable pancreatic cancer (BRPC) or locally advanced pancreatic cancer (LAPC) who achieved pathologic complete response (pCR) following neoadjuvant therapy. MATERIALS AND METHODS: A single institution clinical database for patients with pancreatic ductal adenocarcinoma was queried. Between 2008 and 2014 patients were identified with BRPC and LAPC, who underwent surgical resection after receiving neoadjuvant treatment. Clinical and pathologic features of the patients who achieved pCR were acquired retrospectively. RESULTS: Six patients were identified to have pCR on pathology of the postoperative specimen. On the basis of pretreatment clinical staging, 2 patients were considered to have BRPC and 4 LAPC. Four patients received gemcitabine-based chemotherapy and 2 patients received FOLFIRINOX (5-fluorouracil, oxaliplatin, irinotecan, and leucovorin). Five of 6 patients received radiation therapy before operative resection. Operative procedures included distal pancreatectomy (n=3) and pancreatoduodenectomy (n=3). Pancreatic intraepithelial neoplasia 1 to 2 was present in 3 cases, and pancreatic intraepithelial neoplasia 3 in 1 case. During a median follow-up of 21.3 months, 2 patients died, with a median survival of 11.0 months (range, 10.4 to 11.6 mo). Four patients are alive and continue to follow-up with median survival of 28.7 months (range, 20.1 to 42.4 mo). CONCLUSIONS: Multimodality neoadjuvant therapy may lead to complete pathologic response in a small number of patients with borderline resectable/locally advanced pancreatic adenocarcinoma. pCR to neoadjuvant therapy does not lead to cure in most cases, and the majority of patients appear to relapse locally or systemically.

Minimally Invasive Incision and Drainage Technique in the Treatment of Simple Subcutaneous Abscess in Adults.

A minimally invasive (MI) approach using small incisions and vessel loops for drainage of simple perianal abscesses has been described in the pediatric population with decreased postoperative pain and comparable results to the traditional incision and drainage (I&D). The hypothesis was MI I&D will yield similar outcomes in adults. Patients who underwent I&D of perianal abscesses at an urban hospital from January 2008 to December 2015 were identified by Current Procedural Terminology code. Patients below 18 years of age, with inflammatory bowel diseases, or fistulae were excluded. Recurrences, readmissions, operative time, length of stay, complications, and costs were compared. There were 47 traditional and 96 MI I&D with no significant differences in demographics, average body mass index, and abscess size. No significant differences were noted in recurrences, readmissions, length of stay, operative time, or costs (P > 0.05). Postoperative complications occurred more frequently in the traditional group (P < 0.01) with a lower rate of follow-up (P < 0.05). MI I&D for simple anal abscesses in adults is associated with better compliance and fewer complications than the traditional approach. Although further studies are needed to determine if MI I&D confers superiority, this approach should be considered as first-line treatment for uncomplicated perirectal abscesses in adults.