Half of Anastomotic Leaks After Esophagectomy Are Undetected on Initial Postoperative Esophagram.

BACKGROUND: The sensitivity of fluoroscopic esophagography with oral administration of contrast material to exclude anastomotic leak after esophagectomy is not well documented, and the consequences of missing a leak in this setting have not been previously described. METHODS: We performed a retrospective cohort study of a prospectively maintained institutional database of patients undergoing esophagectomy with esophagogastric anastomosis from 2008 to 2020. Relevant details of leaks, management, and outcomes were obtained from the database and formal chart review. Statistical analysis was performed to compare patients with and without leaks and those with false-negative vs positive esophagrams. RESULTS: There were 384 patients who underwent esophagectomy with gastric reconstruction; the majority were Ivor-Lewis (82%), and 51% were wholly or partially minimally invasive. By use of a broad definition of leak, 55 patients (16.7%) developed an anastomotic leak. Of the 55 patients, 27 (49%) who ultimately were found to have a leak initially had a normal esophagram result (performed on average on postoperative day 6). Those with a normal initial esophagram result were more likely to have an uncontained leak (81% vs 29%; P < .01), to require unplanned readmission (70% vs 39%; P = .02), and to undergo reoperation (44% vs 11%; P < .01). CONCLUSIONS: Early postoperative esophagrams intended to evaluate anastomotic integrity have a low sensitivity of 51%, and leaks missed on the initial esophagram have greater clinical consequences than those identified on the initial esophagram. These findings suggest that a high index of suspicion must be maintained even after a normal esophagram result and call into question the common practice of using this test to triage patients for diet advancement.

Video- and Robotic-Assisted Thoracoscopic Truncal Vagotomy.

A subset of patients with marginal ulcers after Roux-en-Y gastric bypass (RNYGB) is refractory to medical management. Here we report a retrospective review of a single institution cohort (N = 10) of video- or robotic-assisted thoracoscopic (VATS or RATS) truncal vagotomies performed between 2013 and 2018. All patients had recurrent marginal ulcers following RNYGB complicated by bleeding or perforation, refractory to medical management for a median of 3.5 months prior to undergoing truncal vagotomy. With a median of 23 months' follow-up, only three patients had continued symptoms (70% symptom resolution) post-operatively. Only one patient who had repeat endoscopy after the procedure had documented endoscopic evidence of recurrent marginal ulcer (83% endoscopic resolution). VATS or RATS truncal vagotomy is a safe and effective method to treat complicated marginal ulceration after RNYGB. After an average duration of unsuccessful medical treatment lasting three months, vagotomy led to successful resolution in 70-83% of patients.

Does Everyone Need High Technology Intervention Before They Die?

A persistent problem in cardiothoracic surgery, as in all of medicine, is when to offer or to withhold expensive technologies. The ethical requirement of balancing harms and benefits is often difficult to achieve. The use of LVADs is an example of such technologies, and when to offer it is explored in this paper.

Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation.

BACKGROUND: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training. METHODS: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation. RESULTS: After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein. CONCLUSIONS: Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

Optimization-driven framework to understand health care network costs and resource allocation.

In the last several decades, the U.S. Health care industry has undergone a massive consolidation process that has resulted in the formation of large delivery networks. However, the integration of these networks into a unified operational system faces several challenges. Strategic problems, such as ensuring access, allocating resources and capacity efficiently, and defining case-mix in a multi-site network, require the correct modeling of network costs, network trade-offs, and operational constraints. Unfortunately, traditional practices related to cost accounting, specifically the allocation of overhead and labor cost to activities as a way to account for the consumption of resources, are not suitable for addressing these challenges; they confound resource allocation and network building capacity decisions. We develop a general methodological optimization-driven framework based on linear programming that allows us to better understand network costs and provide strategic solutions to the aforementioned problems. We work in collaboration with a network of hospitals to demonstrate our framework applicability and important insights derived from it.

Paging Patterns Among Junior Surgery Residents in a Tertiary Care Center.

OBJECTIVE: An excessive amount of nonurgent pages may disrupt patient care, reduce efficiency, and contribute to burnout. We present detailed paging data to analyze frequency, content, and urgency of pages received by surgery residents to provide recommendations to reduce resident distractions and fatigue. DESIGN: Prospective review of pages received by surgery residents over 15 weeks in 2019. Pages were analyzed by content and urgency (routine, important, emergent) by author consensus and compared among day and night shifts, and page senders' profession. SETTING: University tertiary-care hospital PARTICIPANTS: Seventeen junior surgery residents (PGY-1 and PGY-2) RESULTS: Total 1,740 resident-hours yielded 1,871 pages. Residents working day and night shift received a median of 11 (IQR 7-14) and 13 (IQR 6-22) pages, respectively. Pages from nurses were most common for both shifts but constituted a significantly increased proportion at night (71.3% vs 36.7%, p < 0.00005). Most pages during day shift were routine (74.4%) and pertained to plan of care and order request (38.4% and 15.7%, respectively). Emergent and important pages were more common at night (8.9% and 24.7% vs 1.8 and 14.8%, p < 0.00005) which paralleled an increase in pages reporting change in patient condition compared to day shift (19.7 from 6.7%, p < 0.00005). Routine pages pertaining care plan and order requests remained common at night (26.5 and 28%, respectively). CONCLUSIONS: Over half of pages received by residents contain routine communications about care plan and request for non-urgent orders, even during night shift. Resident-nurse collaboration and support from technology services might optimizing communication pathways.

Insurance status and waiting times for hospital-based services in Ireland.

In Ireland long waits for public hospital services are a feature of the healthcare system, with limited evidence that waits for private hospital services (delivered in both public and private hospitals) are shorter. In 2008, in an attempt to ensure more equitable access to hospital-based services, a 'common waiting list' for all patients within public hospitals was proposed. The aim of this paper is to analyse waiting times in Ireland for hospital services for patients with and without private health insurance (PHI) and to examine whether the 2008 reform reduced the differential in waiting. The analysis used data from the 2007 and 2010 health module of the Quarterly National Household survey (QNHS). The impact of insurance status on waiting times was analysed for the period before and after the reforms. A higher proportion of those without PHI were waiting more than three months for hospital services relative to those with PHI. There was no evidence that the 2008 reforms reduced the differential. Anecdotal evidence suggests that the proposals were not fully implemented, although expansion of capacity for private patients' treatment in private hospitals is a possible confounding factor.

Convex Probe EBUS-guided Fiducial Placement for Malignant Central Lung Lesions.

BACKGROUND: Stereotactic body radiotherapy (SBRT) had become a therapeutic modality in patients with primary tumors, locally recurrent as well as oligometastasis involving the lung. Some modalities of SBRT require fiducial marker (FM) for dynamic tumor tracking. Previous studies have focused on evaluating bronchoscopic-guided FM placement for peripheral lung nodules. We describe the safety and feasibility of placing FM using real-time convex probe endobronchial ultrasound (CP-EBUS) for SBRT in patients with centrally located hilar/mediastinal masses or lymph nodes. METHODS: This is a retrospective review of patients who were referred to Beth Israel Deaconess Medical Center's multidisciplinary thoracic oncology program for FM placement to pursue SBRT. RESULTS: Thirty-seven patients who underwent real-time CP-EBUS were included. Patients had a median age of 71 years [interquartile range (IQR), 59.5 to 80.5]. The median size of the lesion was 2.2 cm (IQR, 1.4 to 3.3 cm). The median distance from the central airway was 2.4 cm (IQR, 0 to 3.4 cm). A total of 51 FMs (median of 1 per patient) were deployed in 37 patients. At the time of SBRT planning, 46 (90.2%) were confirmed radiologically in 32 patients. Patients with unsuccessful fiducial deployment (n=5) underwent a second procedure using the same technique. Of those, 3 patients had a successful fiducial placement via bronchoscopy, 1 patient required FM placement by percutaneous computed tomography-guided approach and 1 patient required FM placement through EUS by gastroenterology. CONCLUSION: CP-EBUS-guided FM placement for patients with malignant lymph nodes and central parenchymal lung lesions appears to be safe and feasible.

Teamwork and Communication Skills in Cardiothoracic Surgery.

Teamwork and communication skills are essential for the safe practice of cardiothoracic surgery. In this article, we will summarize the literature on teamwork and the culture of safety, and discuss how surgeons may directly improve the outcomes of their patients by addressing these factors.

Public Perceptions of Overlapping Surgery.

BACKGROUND: Overlapping surgery is highly contentious, both in terms of the safety of the practice and the degree to which patients should be informed. However, no study has surveyed attitudes of the general public toward overlapping surgery and willingness to consent to such a procedure. STUDY DESIGN: A survey on overlapping surgery was completed by participants using Amazon Mechanical Turk, an online crowd-sourcing worksite. Responders completed a 51-question survey on their knowledge of overlapping surgery, expectations on disclosure during the informed consent process, and their willingness to participate in such a procedure. In addition, responders completed the Health Care System Distrust Scale. RESULTS: The survey was completed by 1,454 respondents. Median age was 33 years (range 21 to 74 years). Only 56 respondents (3.9%) had any knowledge of the practice of overlapping surgery. Overall, 440 respondents (31%) supported or strongly supported this practice. The majority of respondents believed that the attending surgeon should inform them in advance of overlapping surgery (94.7%), define what the critical components of the operation are (95.6%), and document what portion of the operation he or she was present for (91.5%). CONCLUSIONS: A small minority of the general public is aware of the practice of overlapping surgery. The majority of responders were not supportive of the practice, although would consider it acceptable in specific circumstances. However, responders consistently reported that the practice of overlapping surgery should be disclosed during the informed consent process.

Maximal Oxygen Uptake--Risk Predictor of NSCLC Resection in Patients With Comorbid Emphysema: Lessons From NETT.

We compared VO2 max values from ACCP Guidelines and from NETT's homogenous NULPD surrogate for predicting operative mortalities. Estimated mid and long-term non-cancer related survival in NETT's subset was also obtained. NETT and ACCP Guideline VO2 max values were similar in the "low" and "mid" risk operative mortality categories but NETT's "high" risk subset showed lower mortality (14% vs. 26%). Estimated non-cancer related survival in NETT "low", "mid" and "high" risk VO2 max categories at two and eight years were 100%, 74%, 59% and 48%, 26%, 14%, respectively. The lower predicted risk in NETT's "high- risk" subset raises the possibility of extending indications for potential curative resection in selected patients. The NETT surrogate also provides hitherto unavailable estimate on long-term non-cancer related survival after potential curative resection of NSCLC and suggests that the operation does not shorten eight-year longevity.

The accuracy of computed tomography to predict completeness of pulmonary fissures. A prospective study.

RATIONALE: Endobronchial valves are a potential alternative to lung volume reduction surgery for advanced emphysema. The greatest improvements in pulmonary function are seen in patients with complete pulmonary fissures, as determined by computed tomography (CT). However, the accuracy of CT to predict completeness of pulmonary fissures has not been compared with the reference standard of direct observation during thoracic surgery. OBJECTIVES: To determine the accuracy of CT scans to predict completeness of pulmonary fissures. METHODS: We conducted a double-blind, prospective trial in which completeness of pulmonary fissures was evaluated by direct observation during thoracic surgery. Preoperative CT scans were independently reviewed by two dedicated thoracic radiologists and completeness of the fissures was recorded and compared with intraoperative findings. MEASUREMENTS AND MAIN RESULTS: The fissures of 46 patients were evaluated. The positive predictive value of CT scan to detect a complete fissure was 100% for the right major fissure and 75% for the left fissure, but only 33% for the right minor fissure. CT scans had a negative predictive value of 29% in evaluation of the right major fissure. CONCLUSIONS: CT scans overestimate completeness of the right minor fissure and underestimate completeness of the right major fissure. These findings may have implications for the use of CT scans to select patients for endobronchial valve insertion.

Evaluation of rigid bronchoscopy-guided percutaneous dilational tracheostomy. A pilot study.

RATIONALE: Rigid bronchoscopy-guided (RBG) percutaneous tracheostomy has been used in patients with morbid obesity, prior neck surgery, distorted airway anatomy, and uncorrected coagulopathy where standard percutaneous dilational tracheostomy (PDT) is relatively contraindicated. OBJECTIVES: This study aims to describe a standardized approach to incorporate RBG-PDT in clinical practice. METHODS AND MEASUREMENTS: Retrospective case series of patients who underwent RBG-PDT from 2008 to 2012 at Beth Israel Deaconess Medical Center. Patient medical records were reviewed for demographics, comorbid conditions, American Society of Anesthesiologists classification, indication for tracheostomy, duration of procedure, and periprocedural complications. MAIN RESULTS: A total of 35 patients underwent RBG-PDT, including 24 men, with a mean age of 66 years (±11 yr; range, 42-88 yr). The mean body mass index was 34 kg/m(2). The mean procedure time was 32 (±10) minutes, with a median of 33 minutes. The most common indication for tracheostomy was failure to wean from mechanical ventilation, followed by tracheal stenosis and tracheobronchomalacia. The most common indications for RBG-PDT were complex airway, obesity, and coagulopathy. There were no periprocedural complications of consequence, or mortality associated with the procedure. CONCLUSIONS: RBG-PDT is safe and effective in a population of high-risk patients who are otherwise not considered good candidates for standard PDT.