Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies Using Near Real-Time Feedback and Individualized Electronic Reporting.

BACKGROUND: Postoperative pulmonary complications can have a significant impact on the morbidity and mortality of patients undergoing major surgeries. Intraoperative lung protective strategies using low tidal volume (TV) ventilation and positive end-expiratory pressure (PEEP) have been demonstrated to reduce the incidence of pulmonary injury and infection while improving oxygenation and respiratory mechanics. The purpose of this study was to develop decision support systems designed to optimize behavior of the attending anesthesiologist with regards to adherence with established intraoperative lung-protective ventilation (LPV) strategies. METHODS: Over a 4-year period, data were obtained from 49,386 procedures and 109 attendings. Cases were restricted to patients aged 18 years or older requiring general anesthesia that lasted at least 60 minutes. We defined protective lung ventilation as a TV of 6-8 mL/kg ideal body weight and a PEEP of ≥4 cm H2O. There was a baseline period followed by 4 behavioral interventions: education, near real-time feedback, individualized post hoc feedback, and enhanced multidimensional decision support. Segmented logistic regression using generalized estimating equations was performed in order to assess temporal trends and effects of interventions on adherence to LPV strategies. RESULTS: Consistent with improvement in adherence with LPV strategies during the baseline period, the predicted probability of adherence with LPV at the end of baseline was 0.452 (95% confidence interval [CI], 0.422-0.483). The improvements observed for each phase were relative to the preceding phase. Education alone was associated with an 8.7% improvement (P < .01) in adherence to lung-protective protocols and was associated with a 16% increase in odds of adherence (odds ratio [OR] = 1.16; 95% CI, 1.01-1.33; P = .04). Near real-time, on-screen feedback was associated with an estimated 15.5% improvement in adherence (P < .01) with a 69% increase in odds of adherence (OR = 1.69; 95% CI, 1.46-1.96; P < .01) over education alone. The addition of an individualized dashboard with personal adherence and peer comparison was associated with a significant improvement over near real-time feedback (P < .01). Near real-time feedback and dashboard feedback systems were enhanced based on feedback from the in-room attendings, and this combination was associated with an 18.1% (P < .01) increase in adherence with a 2-fold increase in the odds of adherence (OR = 2.23; 95% CI, 1.85-2.69; P < .0001) between the end of the previous on-screen feedback phase and the start of the individualized post hoc dashboard reporting phase. The adherence with lung-protective strategies using the multidimensional approach has been sustained for over 24 months. The difference between the end of the previous phase and the start of this last enhanced multidimensional decision support phase was not significant (OR = 1.08; 95% CI, 0.86-1.34; P = .48). CONCLUSIONS: Consistent with the literature, near real-time and post hoc reporting are associated with positive and sustained behavioral changes aimed at adopting evidence-based clinical strategies. Many decision support systems have demonstrated impact to behavior, but the effect is often transient. The implementation of near real-time feedback and individualized post hoc decision support tools has resulted in clinically relevant improvements in adherence with LPV strategies that have been sustained for over 24 months, a common limitation of decision support solutions.

Cardiorespiratory Events Associated With Ophthalmic Surgery: A Single-Center, Retrospective Records Review of 130 775 Patients, 1999-2015.

Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases-9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event (P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that "the eye is the window to our overall health" seems to be correct.

Ophthalmic Surgery in Patients with Left Ventricular Assist Devices.

The newer generation of left ventricular assist devices (LVADs) are commonly used as destination therapy; these devices have demonstrated improved outcomes and increased survival. Given the longer lifespan, it is not surprising that patients with LVADS are increasingly presenting with noncardiac, chronic diseases and interventions for their treatment. This includes ophthalmic procedures in patients with LVAD. There is a paucity of literature about the experiences and outcomes in this cohort of patients presenting for ophthalmologic surgery. Here we present a case series consisting of 7 patients with LVAD that underwent 10 ophthalmic surgeries. No adverse events including intraoperative hemodynamic instability or respiratory compromise occurred. All patients had an on-time discharge with no 30-day recidivism. Most patients underwent a phacoemulsification with intraocular lens implantation and received a topical with intracameral anesthetic. We attribute these successful outcomes to a standardized clinical workflow consisting of careful preoperative screening, communication and presence of VAD coordinator, continuation of antithrombotics, monitoring based on presence of pulsatile flow, and a plan for rapid transfer if needed.

Incidence of Venous Air Embolism During Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures. METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed. RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE's occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed. CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.

Safety Comparison of Laryngeal Mask Use With Endotracheal Intubation in Patients Undergoing Dacryocystorhinostomy Surgery.

PURPOSE: This study will determine the safety of laryngeal mask airway (LMA) compared with endotracheal tube (ETT) in patients undergoing general anesthesia for dacryocystorhinostomy (DCR) surgery. METHODS: In this retrospective cohort study, intraoperative and postoperative outcomes of patients who underwent DCR at UAB Callahan Eye Hospital using either LMA or ETT were compared. RESULTS: Over a period of 52 months, 429 patients underwent external DCR surgery. An ETT was used in 37 patients and LMA in 392 patients. Baseline patient characteristics and anesthetic management were similar. No documented cases of blood or gastric aspiration occurred in the total cohort. Our study confirmed the findings of others that there is less cardiovascular lability on LMA placement than with ETT intubation. A 30% increase in heart rate from baseline after intubation (ETT 10.8%, LMA 1.8%; p = 0.010) and after incision (ETT 8.1%, LMA 1.8%; p = 0.047) occurred more frequently in the ETT group. Airway management with an LMA was also less difficult compared with an ETT (ETT 5.7%, LMA 0.5%; p = 0.035). CONCLUSIONS: The use of an LMA for airway control is safe and effective in patients undergoing general anesthesia for DCR surgery. No events of aspiration occurred with LMA use. Heart rate increase was significantly less in the LMA group. In our opinion, use of an LMA for airway control during DCR surgery is superior to use of an ETT. Airway protection, improved hemodynamics, and less difficulty in placement of the laryngeal airway device are all validated by this study.

Outcomes of Patients Who Undergo Cardiac Surgical Procedures After Liver Transplantation.

BACKGROUND: There is a paucity of information available regarding the impact of cardiac surgical procedures on patients who have undergone previous liver transplantation. The primary purpose of this study was to ascertain the survival rate and predictors of death in this specific patient population. METHODS: This retrospective cohort study consisted of a consecutive series of patients with a functioning liver allograft who subsequently underwent cardiac surgical procedures between January 1991 and December 2012. The optimal Model for End-Stage Liver Disease (MELD) score for predicting late death was identified using receiver operating characteristic curve analysis. Risk of postoperative death was determined by parametric hazard analysis. RESULTS: Between January 1991 and December 2012, 43 patients (median age, 60 years) underwent cardiac surgical procedures after liver transplantation. The median interval between liver transplant and cardiac operation was 63 months (range, 1.1 to 217 months). Three operative deaths and 24 late deaths occurred. Receiver operating characteristic curve analysis identified the optimal preoperative and postoperative MELD score cut points for predicting late death as greater than 13.8 (area under the curve = 0.674) and greater than 17 (area under the curve = 0.633), respectively. Patients with a preoperative MELD score of 13.8 or less had significantly greater survival rates than those with a MELD score greater than 13.8 (p = 0.028); patients with a postoperative MELD score of 17 of less had significantly greater survival rates than those with a MELD score greater than 17 (p < 0.001). Multivariate parametric hazard analysis identified postoperative peak creatinine level as a statistically significant predictor of death (relative risk, 1.8; p = 0.01). The 1-, 5-, and 10-year Kaplan-Meier survival rates were 90%, 51%, and 35%, respectively; postoperative mortality rates followed a constant phase model with a hazard of death of 10% per year. CONCLUSIONS: Cardiac surgical procedures can be performed with acceptable short-term and long-term outcomes in liver transplant recipients. Elevated preoperative and postoperative MELD scores and postoperative peak creatinine level may portend death in this cohort. There is a constant hazard of death of 10% per year.

Late Left Ventricular Outflow Tract Obstruction Following the Rastelli Operation: Expectations Out to 20 Years.

BACKGROUND: Consensus is lacking regarding the optimal operation for transposition, ventricular septal defect, and pulmonary stenosis. METHODS: Between 1968 and 2012, a total of 76 patients underwent the Rastelli procedure, with 52 mid- or long-term survivors. A bracketing analysis was used to estimate the likelihood of late left ventricular outflow tract obstruction (LVOTO). RESULTS: Early mortality decreased over the period of study, with no hospital mortality since 2000. Among one year survivors, 10- and 20-year survival was 90% and 72%, respectively. Freedom from reoperation for LVOTO was 87% at 20 years, with no increase in risk among patients having the procedure before 5 years of age. Available late echocardiographic or catheterization data indicated mild or no LVOTO at a median of 14.3 years in a subset of 38 patients. Estimated freedom from major LVOTO at 20 years is bracketed between the estimate of 87% freedom from reoperation for LVOTO at 20 years and the 78% freedom from reoperation for LVOTO or cardiac death by 20 years. CONCLUSION: The Rastelli operation can be performed in the current era with an early mortality that approaches 0% and with 20-year survival that exceeds 70%. The late risk of important LVOTO appears to range from about 13% to 22% at 20 years, with no increase in risk among patients operated upon before the age of 5 years.

Early Postoperative Albumin Administration Contributes to Morbidity After the Fontan Operation.

The Fontan operation has low mortality, but is associated with significant postoperative morbidity, including prolonged chest tube output (PCTO), which is associated with prolonged hospital length of stay (PLOS). We sought to identify variables present early in the clinical course that could predict patients at high risk for PCTO and PLOS. Retrospective data were collected on 84 Fontan (extracardiac conduit) operations from 1/2008 to 12/2013 at a single institution. PCTO was defined as ≥8 days (>75th percentile); PLOS was defined as ≥12 days postoperatively (>75th percentile). Multivariate regression was used to determine covariates associated with PCTO and PLOS. Median age was 3.5 years (IQR 3-5); weight was 14.5 kg (IQR 13-17). There was no mortality. LOS was 9 days (IQR 3-11), and duration of chest tube drainage 6 days (IQR 5-8) at 15 ml/kg/day (IQR 9-20). In univariate analysis, only systemic right ventricle, 24-h 5 % albumin administration, 24-h fluid balance, and 12-h inotrope score were associated with PCTO. In multivariate analysis, only 5 % albumin administration in first 24 h (p < 0.001) and PCTO were independently associated with PLOS. ROC curve analysis showed patients receiving >25 ml/kg of 5 % albumin in first 24-h predicted PLOS (94 % specificity, 93 % sensitivity, AUC = 0.95, p < 0.001). Increased colloid in the first 24-h post-CPB strongly predicts PCTO and PLOS after Fontan operation, potentially providing an early identification of a cohort with unfavorable Fontan physiology. A better understanding of the role of colloid resuscitation after Fontan is necessary, and efforts to reduce perioperative colloid administration could decrease hospital morbidity.

Health-Related Quality of Life in Adult Survivors After the Fontan Operation.

The primary objective of this study was to ascertain the long-term health-related quality of life (HRQOL) of adult patients who underwent a childhood Fontan operation for palliation of univentricular cardiac anomalies. The secondary objective was to compare the long-term HRQOL of Fontan survivors to that of pediatric heart transplant recipients. This cross-sectional study examined adult survivors (>19 years) who underwent a Fontan operation during childhood (Fontan group) or a pediatric heart transplant (HT group) between 1988 and 2011 (23-year span). HRQOL was assessed using the short form 36 survey. The study group consisted of 49 Fontan group patients and 13 HT group patients who responded to the survey. HRQOL scores of the Fontan group were similar to those of an age-controlled healthy US population in social and mental functioning, energy or vitality, and overall mental component score (P ≥ 0.2). However, Fontan scores in physical functioning, bodily pain, general health, and overall by physical component were significantly lower than those of the age-controlled US population (P < 0.05). No differences were identified between Fontan and HT patients. This favorable life-satisfaction period (average 18 years) should be considered when informing patients and families of expectations with the Fontan pathway vs certain higher-risk procedures.

Surgical and Anesthetic Management of a Mediastinal Fatty Tumor: Lipoblastoma.

Lipoblastoma is a rare fatty tumor that is diagnosed almost exclusively in children. Presentation often consists of respiratory symptoms; chest computed tomography shows a hypodense, low, attenuated mediastinal mass. Surgical approach and anesthetic management are dependent on the location of the tumor and the degree of airway compression; in most cases, a thoracotomy is performed, although a sternotomy is used in selected cases. Final diagnosis can be confirmed using molecular genetic analysis; a genetic hallmark of lipoblastoma is the rearrangement of chromosomal region 8q12 and the PLAG1 gene. Tumor recurrence is rare when a complete resection is performed.

Retention Rate of Electromagnetic Navigation Bronchoscopic Placed Fiducial Markers for Lung Radiosurgery.

BACKGROUND: Radiosurgery is becoming an increasingly used modality for the medically inoperable early stage lung cancer patient. The optimal fiducial marker with respect to retention rate has yet to be identified. METHODS: We retrospectively reviewed our experience with electromagnetic navigational bronchoscopic fiducial marker placement in preparation for stereotactic radiosurgery. RESULTS: Forty-eight patients, treated between 2010 and January 2013, were retrospectively reviewed. All patients had a diagnosis of early stage lung cancer. Comparison of initial fiducial placement procedure data with imaging at the time of treatment was accomplished for all patients in this data set. Fiducial retention rates were as follow: VortX coil fiducials were retained in 59 of 61 (96.7%) cases; two-band fiducials were retained in 24 of 33 (72.7%) of instances; and gold seed fiducials were retained in 23 of 33 (69.7%) of cases. Retention was statistically superior when comparing the VortX coil with the two-band fiducial or the gold seed (p = 0.004 and p = 0.0001). Anatomic location by lobe was analyzed, but no statistically significant differences were observed. CONCLUSIONS: The VortX coil fiducial marker showed a statistically significant increase in retention rate compared with gold seeds or two-band fiducials. This may translate to cost savings through placing fewer markers per patient as retention is high.

The efficacy of restaging endobronchial ultrasound in patients with non-small cell lung cancer after preoperative therapy.

BACKGROUND: Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy. METHODS: This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy. RESULTS: There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively. CONCLUSIONS: Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.

The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection.

BACKGROUND: Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). METHODS: This is a retrospective review of patients who underwent pulmonary resection with MLND. RESULTS: Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 µg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. CONCLUSIONS: Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes.

BACKGROUND: The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy. METHODS: This was a retrospective review of a consecutive series of patients. RESULTS: From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit. CONCLUSIONS: Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving.

The safety and efficacy of mediastinoscopy when performed by general thoracic surgeons.

BACKGROUND: Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons. METHODS: A retrospective cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only. RESULTS: Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard. CONCLUSIONS: In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.

Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video-assisted thoracoscopic sympathotomy for hyperhidrosis.

OBJECTIVE: The objective of the present study was to determine the long-term fate and factors of compensatory hyperhidrosis (CH) in patients who have undergone video-assisted thoracoscopic sympathotomy for focal hyperhidrosis. METHODS: The same quality-of-life survey was administered 6 months postoperatively and then annually to all patients who underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis. A second rib (R2)/R3 sympathotomy was most commonly performed until September 2007 and then R4/R5 sympathotomy was used. RESULTS: From January 1999 until December 2012, 193 patients underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis, of whom, 173 had provided ≥1 year of postoperative survey information. No operative mortalities occurred. Of the 173 patients, 133 (77%) reported "clinically bothersome" CH. This rate had decreased to an average of 35% at 5 and 12 years postoperatively. Univariate analysis showed the CH incidence was significantly greater for the patients who had undergone R2/R3 versus R4/R5 sympathotomy (P < .001), had had multiple sites of sweating at presentation (P < .001), had used oral medication to control hyperhidrosis preoperatively (P = .022), or were female (P = .002). On multivariate analysis, only R2/R3 versus R4/R5 sympathotomy (P < .021) and multiple sites of sweating at presentation (P < .037) remained statistically significant. Twelve patients (6.2%) regretted having the operation for CH. CONCLUSIONS: Patients who undergo sympathotomy for hyperhidrosis will commonly report "clinically bothersome" compensatory hyperhidrosis. CH will more likely if R2/R3 sympathetic interruption has been performed instead of R4/R5 and in patients who present with multiple areas of sweating. The severity of clinically bothersome CH decreased during the first 3 years postoperatively.

Quality of life after pulmonary resections.

Quality of life (QOL) is an important component of the conversation between any physician and patient. It is especially important between a surgeon and an operative candidate when considering treatment of lung cancer. Patients want reassurance that after removal of part of their lung that not only will they be cancer-free but also that they will be able to breathe well even when active. They do not want to be left physically or mentally handicapped. Recent studies have also shown the correlation between QOL and survival after resection. In this article the literature concerning QOL after pulmonary resection is reviewed.

Optimal technique for the removal of chest tubes after pulmonary resection.

OBJECTIVE: The objective is to determine the optimal manner to remove a chest tube after pulmonary resection. METHOD: This was a prospective, randomized single-institution study. Patients who underwent elective thoracotomy for pulmonary resection by 1 or 2 general thoracic surgeons were randomized to have their chest tube removed on either full inspiration or full expiration. Both patient groups performed a Valsalva maneuver during tube removal. Outcomes included the incidence of clinically nonsignificant pneumothorax (defined as a new or increased pneumothorax on the post-chest tube removal chest roentgenogram in asymptomatic patients), symptoms, delayed discharge, and the need for a new chest tube. RESULTS: Between November 2008 and June 2011, 1189 patients underwent pulmonary resection, and of these 342 met the criteria for the study. Of the 179 patients randomized to have their chest tube removed on full inspiration, 58 (32%) had a larger or new pneumothorax after chest tube removal and 5 (3%) required intervention or delayed discharge. Of the 163 patients randomized to have their chest tube removed on full expiration, 32 (19%; P = .007) had a larger or new pneumothorax after chest tube removal, and only 2 (1%) required intervention or delayed discharge (P = .78). CONCLUSIONS: Removal of chest tubes at the end of expiration leads to a lower incidence of non-clinically significant pneumothorax than at the end of inspiration. Because of these findings, this study was closed early and was thus underpowered for finding a statistically significant difference in the rare (1%-3%) clinically significant pneumothoraces.