The Office of Belonging, Equity, Diversity, and Inclusion in The Warren Alpert Medical School: Aligning Goals, Programming, and Outcomes for Health Equity.

Although United States (US) medical institutions discuss the importance of diversity, equity, and inclusion, there is little guidance about the process by which these concepts can be attained programmatically within institutions. The Office of Belonging, Equity, Diversity, and Inclusion (OBEDI) at The Warren Alpert Medical School of Brown University intends to rise to the challenge and share knowledge and experience with other institutions. Program design models, and the alignment of inputs, outputs, and outcomes for the short-term and long-term are illustrated. OBEDI's unique model of how each of these concepts contribute towards health equity, from the individual to the community, is also explained. Finally, OBEDI shares promising practices and future directions.

Impact of Prehabilitation on Postoperative Mortality and the Need for Non-Home Discharge in High-Risk Surgical Patients.

BACKGROUND: The preoperative period is an important target for interventions (eg Surgical Prehabilitation and Readiness [SPAR]) that can improve postoperative outcomes for older patients with comorbidities. STUDY DESIGN: To determine whether a preoperative multidisciplinary prehabilitation program (SPAR) reduces postoperative 30-day mortality and the need for non-home discharge in high-risk surgical patients, surgical patients enrolled in a prehabilitation program targeting physical activity, pulmonary function, nutrition, and mindfulness were compared with historical control patients from 1 institution's American College of Surgeons (ACS) NSQIP database. SPAR patients were propensity score-matched 1:3 to pre-SPAR NSQIP patients, and their outcomes were compared. The ACS NSQIP Surgical Risk Calculator was used to compare observed-to-expected ratios for postoperative outcomes. RESULTS: A total of 246 patients were enrolled in SPAR. A 6-month compliance audit revealed that overall patient adherence to the SPAR program was 89%. At the time of analysis, 118 SPAR patients underwent surgery with 30 days of follow-up. Compared with pre-SPAR NSQIP patients (n = 4,028), SPAR patients were significantly older with worse functional status and more comorbidities. Compared with propensity score-matched pre-SPAR NSQIP patients, SPAR patients had significantly decreased 30-day mortality (0% vs 4.1%, p = 0.036) and decreased need for discharge to postacute care facilities (6.5% vs 15.9%, p = 0.014). Similarly, SPAR patients exhibited decreased observed 30-day mortality (observed-to-expected ratio 0.41) and need for discharge to a facility (observed-to-expected ratio 0.56) compared with their expected outcomes using the ACS NSQIP Surgical Risk Calculator. CONCLUSIONS: The SPAR program is safe and feasible and may reduce postoperative mortality and the need for discharge to postacute care facilities in high-risk surgical patients.

Routine Collection of Patient-Reported Outcomes in Thoracic Surgery: A Quality Improvement Study.

BACKGROUND: Patient-reported outcomes are critical for delivering high-quality surgical care, yet they are seldom collected in routine clinical practice. The objective of this quality improvement study was to improve routine patient-reported outcomes collection in a thoracic surgery clinic. METHODS: Thoracic surgery patients at a single academic institution were prospectively monitored from April 2019 to March 2020. The National Institutes of Health-validated Patient-Reported Outcomes Measurement Information System (PROMIS) was used. Using a Model for Improvement design and through multidisciplinary participant observation, we performed multiple plan-do-study-act cycles, an iterative, 4-stage model for rapidly testing interventions, to improve routine collection reliability. RESULTS: During the study period, 2315 patient visits occurred. The baseline PROMIS assessment collection rate was 53%. After convening a multidisciplinary stakeholder team, the key drivers for PROMIS collection were having engaged staff, engaged patients, adequate technological capacity, and adequate time for survey completion, including when to complete the survey during the patient visits. Regular meetings between stakeholders were initiated to promote these key drivers. Several plan-do-study-act cycles were then used to test different interventions, resulting in several positive system shifts, as demonstrated on a statistical process control chart. Adherence to survey collection reached 91% of office visits by approximately 7 months, a 72% relative improvement, which was sustained. CONCLUSIONS: Routine collection of patient-reported outcomes, such as PROMIS, are critical for improving thoracic surgical care. Our study shows that reliably collecting these data is possible in a clinical setting with minimal additional hospital resources.

Combination of Oral Antibiotics and Mechanical Bowel Preparation Reduces Surgical Site Infection in Colorectal Surgery.

BACKGROUND: Surgical site infections (SSI) are a common complication after colorectal surgery. An infection prevention bundle (IPB) was implemented to improve outcomes. STUDY DESIGN: A standardized IPB that included the administration of oral antibiotics with a mechanical bowel preparation, preoperative shower with chlorhexidine, hair removal and skin preparation in holding, antibiotic wound irrigation, and a "clean-closure" protocol was implemented in January 2013. Data from the American College of Surgeons NSQIP were analyzed at a single academic institution to compare pre-IPB and post-IPB SSI rates. In January 2014, a prospective database was implemented to determine compliance with individual IPB elements and their effect on outcomes. RESULTS: For the 24 months pre-IPB, the overall SSI rate was 19.7%. During the 30 months after IPB implementation, the SSI rate decreased to 8.2% (p < 0.0001). A subset of 307 patients was identified in both NSQIP and our prospective compliance databases. Elements of IPB associated with decreased SSI rates included preoperative shower with chlorhexidine (4.6% vs 16.2%; p = 0.005), oral antibiotics (3.4% vs 15.4%; p < 0.001), and mechanical bowel preparation (4.4% vs 14.3%; p = 0.008). Patients who received a full bowel preparation of both oral antibiotics and a mechanical bowel preparation had a 2.7% SSI rate compared with 15.8% for all others (p < 0.001). On multivariate analysis, full bowel preparation was independently associated with significantly fewer SSI (adjusted odds ratio 0.2; 95% CI 0.1 to 0.9; p = 0.006). CONCLUSIONS: Implementation of an IPB was successful in decreasing SSI rates in colorectal surgery patients. The combination of oral antibiotics with a mechanical bowel preparation was the strongest predictor of decreased SSI.

Suction rectal biopsy yields adequate tissue in children.

BACKGROUND/PURPOSE: Hirschsprung disease (HD) is diagnosed by rectal biopsy, with suction rectal biopsy (SRB), the preferred technique in neonates. Reported SRB adequacy has varied overall with concern for decreased diagnostic yield in older children. The study aim was to assess SRB adequacy by age in children with the current device used at our institution. METHODS: Following IRB approval, a retrospective cohort of children (1 to 18years) evaluated by SRB for HD was identified through billing records. Data regarding demographics, procedure, results, and complications were collected and analyzed using SPSS. RESULTS: 56 children (median age 3.9years) underwent SRB with an 80.4% overall success rate. Patients older than 5years had 90.5% adequacy rate compared to 74.3% in those younger. Univariate analysis revealed weak association of inadequate specimens with younger age and males, and no association with insurance, race/ethnicity, weight-height or BMI percentile, sedation type, or procedure location. SRB under general anesthesia (GA) had 100% adequacy (n=6). Patients with inadequate initial biopsy achieved diagnosis by SRB with increased sedation (n=5) or full thickness biopsy under GA (n=5). CONCLUSION: With adequacy of 80.4% overall and 90.5% for patients greater than 5years, SRB is effective in evaluating the older child for HD.

Early Biventricular Assist Device Use in Children: A Single-Center Review of 31 Patients.

Biventricular assist device (BiVAD) support is considered a risk factor for worse outcomes compared with left ventricular assist device (LVAD) alone for children with end-stage heart failure. It remains unclear whether this is because of the morbidity associated with a second device or the underlying disease severity. We aimed to show that early BiVAD support can result in good survival by analyzing our prospectively collected database for all pediatric patients who underwent BiVAD implantation. From 2005 to 2009, BiVADs were used exclusively. From 2010 to 2014, LVAD alone was considered, maintaining a low threshold for BiVAD support. All BiVADs were pulsatile devices. Thirty-one patients with median age of 3.5 years received BiVAD support. Diagnoses included dilated cardiomyopathy in 17 (55%), myocarditis in 6 (19%), and congenital heart disease in 3 (10%). Survival to transplant was achieved in 27 (87%) with a median duration of 41 days (interquartile range, 15-69). Adverse event rates (per 100 days of support) were bleeding at 0.52, infection at 1.17, and central nervous system dysfunction at 0.78. Of those who survived to transplant, 26 (96%) remain alive with a median follow-up of 55 months. These results show that BiVAD support can bridge patients to transplant with excellent long-term survival.

Outcomes of repeat mitral valve surgery in patients with pulmonary hypertension.

OBJECTIVE: We sought to study the outcomes of redo-mitral valve surgery in patients with pulmonary hypertension. METHODS: We reviewed data on redo mitral valve surgery in patients with pulmonary hypertension measured by Swan-Ganz catheter (mean pulmonary artery pressure ≥ 25 mm Hg or systolic pulmonary artery pressure ≥ 40 mm Hg). RESULTS: Between 1996 and 2010, 637 patients underwent 658 redo mitral valve operations; 138 of them had pulmonary hypertension. The mean patient age was 61.3 (13.9) years, with mean left ventricular ejection fraction of 47.6% (13.2%). The mean systolic pulmonary artery pressure was 61.5 (16.8) mm Hg, and mean pulmonary artery pressure was 40.8 (11.6) mm Hg. Patients had one (71%, 98/138), two (23.9%, 33/138), and three (5.1%, 7/138) previous mitral valve operations. Thirty-day mortality was 10.1% (14/138). Multivariate predictors of 30-day mortality were chronic renal failure [odds ratio (OR), 8.041; P = 0.022], peripheral vascular disease (OR, 5.976; P = 0.025), previous mitral valve replacement (OR, 9.034; P = 0.014), and increasing age (OR, 1.077; P = 0.013). The severity of pulmonary hypertension did not impact 30-day (P = 0.314) or late mortality (P = 0.860). Kaplan-Meier survival rates at 1, 3, and 5 years were 76.6% (n = 99), 65.7% (n = 62), and 55.9% (n = 41), respectively. CONCLUSIONS: Patients with pulmonary hypertension that undergo redo mitral valve surgery have a 55.9% 5-year survival rate. Increasing age, chronic renal insufficiency, peripheral vascular disease, and preexisting mitral valve prosthesis are associated with early mortality. The severity of pulmonary hypertension does not affect operative mortality rates, but it may decrease 1-, 3-, and 5-year survival.

Postoperative radiotherapy for pathologic N2 non-small-cell lung cancer treated with adjuvant chemotherapy: a review of the National Cancer Data Base.

PURPOSE: To investigate the impact of modern postoperative radiotherapy (PORT) on overall survival (OS) for patients with N2 non-small-cell lung cancer (NSCLC) treated nationally with surgery and adjuvant chemotherapy. PATIENTS AND METHODS: Patients with pathologic N2 NSCLC who underwent complete resection and adjuvant chemotherapy from 2006 to 2010 were identified from the National Cancer Data Base and stratified by use of PORT (≥ 45 Gy). A total of 4,483 patients were identified (PORT, n = 1,850; no PORT, n = 2,633). The impact of patient and treatment variables on OS was explored using Cox regression. RESULTS: Median follow-up time was 22 months. On univariable analysis, improved OS correlated with younger age, treatment at an academic facility, female sex, urban population, higher income, lower Charlson comorbidity score, smaller tumor size, multiagent chemotherapy, resection with at least a lobectomy, and PORT. On multivariable analysis, improved OS remained independently predicted by younger age, female sex, urban population, lower Charlson score, smaller tumor size, multiagent chemotherapy, resection with at least a lobectomy, and PORT (hazard ratio, 0.886; 95% CI, 0.798 to 0.988). Use of PORT was associated with an increase in median and 5-year OS compared with no PORT (median OS, 45.2 v 40.7 months, respectively; 5-year OS, 39.3% [95% CI, 35.4% to 43.5%] v 34.8% [95% CI, 31.6% to 38.3%], respectively; P = .014). CONCLUSION: For patients with N2 NSCLC after complete resection and adjuvant chemotherapy, modern PORT seems to confer an additional OS advantage beyond that achieved with adjuvant chemotherapy alone.

Left main disease progression following left branch vessel percutaneous intervention in patients who are referred for coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: We studied patients presenting for coronary artery bypass grafting (CABG) with significant left main coronary artery disease (LMD) despite previously documented minimal or no LMD at percutaneous coronary intervention (PCI) for left-sided branch coronary artery disease. METHODS: Patients undergoing CABG for LMD with previous PCI were separated into fast or slow stenosis progression using percent change in LMD from first PCI to CABG divided by time (progression velocity). Outcomes and Kaplan-Meier survival were compared between the two groups. RESULTS: Between September 1997 and June 2010, 4837 patients underwent CABG with 1235 of them having previous PCI of which 118 had LMD and previous left-sided branch PCI. Using median progression velocity fast and slow progression groups were identified (0.53 ± 0.18 and 4.5 ± 4.8%/month, p < 0.001). Mean follow-up was 4.9 ± 3.6 years and 6.9 ± 3.9 years, respectively. Fast progression patients were younger (p = 0.042), with higher baseline LMD at PCI (16.4% vs. 9% stenosis, p = 0.025), and a mean of 2.5 years to LMD compared to 10.6 years for the slow group (p < 0.001). There was no difference between the groups in number or type of PCI and number or type of vessel intervened. Kaplan-Meier survival was similar at one, three, and five years. CONCLUSIONS: Fast LMD progression patients were younger and made up 4.7% (59/1235) of patients undergoing CABG with a history of PCI. Rapid progression was not related to number, type of PCI, or branch vessel intervened.

National patterns of care and outcomes after combined modality therapy for stage IIIA non-small-cell lung cancer.

INTRODUCTION: The role of surgery in addition to chemotherapy and radiation for stage IIIA non-small-cell lung cancer (NSCLC) remains controversial. Because there are limited data on the benefit from surgery in this setting, we evaluated the use of combined modality therapy nationally and explored the outcomes with and without the addition of surgery. METHODS: Patient variables and treatment-related outcomes were abstracted for patients with clinical stage IIIA NSCLC from the National Cancer Database. Patients receiving chemotherapy and radiation were compared with those undergoing chemotherapy, radiation, and surgery (CRS) in any sequence. RESULTS: Between 1998 and 2010, 61,339 patients underwent combined modality treatment for clinical stage IIIA NSCLC. Of these, 51,979 (84.7%) received chemotherapy and radiation while 9360 (15.3%) underwent CRS. Patients in the CRS group were younger, more likely female patients and Caucasians, and had smaller tumors and lower Charlson comorbidity scores. The 30-day surgical mortality was 200 of 8993 (2.2%). The median overall survival favored the CRS group in both unmatched (32.4 months versus 15.7 months, p < 0.001) and matched analysis based on patient characteristics (34.3 versus 18.4 months, p < 0.001). CONCLUSIONS: There is significant heterogeneity in the treatment of stage IIIA NSCLC in the United States. Patients selected for surgery in addition to chemoradiation therapy seem to have better long-term survival.

Incremental risk of the Cox-maze IV procedure for patients with atrial fibrillation undergoing mitral valve surgery.

OBJECTIVE: More than 50% of atrial fibrillation surgery occurs in the setting of mitral valve surgery. Despite this, no risk models have been validated for concomitant arrhythmia surgery. The purpose of the present study was to quantify the additional risk of performing the Cox-maze IV procedure for patients undergoing mitral valve surgery. METHODS: From January 2002 to June 2011, 213 patients with mitral valve disease and preoperative atrial fibrillation underwent mitral valve surgery only (n = 109) or in conjunction with a Cox-maze IV procedure (n = 104). The operative mortality for the mitral valve procedure alone was predicted for each group using the Society of Thoracic Surgeons perioperative risk calculator. The risk attributed to the added Cox-maze IV procedure was calculated by comparing the predicted mortality rate of an isolated mitral valve procedure and the actual mortality rate of mitral valve surgery with a concomitant Cox-maze IV procedure. RESULTS: For patients not undergoing a Cox-maze IV procedure, the predicted and actual postoperative mortality rate was 5.5% and 4.6% (5 of 109), respectively. For patients receiving mitral valve surgery and a concomitant Cox-maze IV, the predicted and actual postoperative mortality of the mitral valve procedure was 2.5% and 2.9% (3 of 104), respectively, and not significantly different. Patients not offered a Cox-maze IV procedure had significantly more serious comorbidities. CONCLUSIONS: For patients with atrial fibrillation and mitral valve disease undergoing mitral valve surgery, the decision to offer a concomitant Cox-maze IV procedure will be influenced by the underlying comorbid conditions. Nonetheless, in selected lower risk patients, the addition of a Cox-maze IV procedure did not significantly affect the procedural mortality.

New directions in medical education related to psychiatry.

The 100-year anniversary of the Flexner report provides an opportunity to reflect on the future of medical education. We will consider the legacy of the original report, the centenary follow up to that report and consider how these, in concert with emerging learning theories, will influence medical education. We first provide a brief overview of the original Flexner report and review the recommendations of the 2010 centenary follow up to the report. We then discuss some of the major developments in learning theory and consider how they have influenced medical education. In general, there has been a gradual shift from passive to active methods, spurred in part by constructivist theories of learning. Many of the attitudes and skills required are particular strengths of the psychiatrist, making psychiatric educators particularly suitable to lead curricular change. Although much literature is devoted to determining the 'best' educational method, we take an ecumenical approach, suggesting that the various pedagogical approaches are all legitimate educational tools from which to choose. Each has its strength and limitations, and when designing a curriculum we should consider these when making pedagogical choices. We finish with some practical advice for those contemplating curricular change.

The impact of CHADS2 score on late stroke after the Cox maze procedure.

OBJECTIVE: The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS2 score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure. METHODS: A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS2 score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery. RESULTS: Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS2 score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS2 score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS2 criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events. CONCLUSIONS: The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS2 score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.

Radial artery free and T graft patency as coronary artery bypass conduit over a 15-year period.

BACKGROUND: The radial artery is often used as the second arterial graft for coronary artery bypass grafting. Little is known about the differences in long-term patency between radial free and T grafts. This study was performed to determine long-term radial artery patency over a 15-year period. METHODS AND RESULTS: Radial arteries were used as free grafts or T grafts for coronary artery bypass grafting over a 15-year period. Patients were contacted to determine if postoperative cardiac catheterization was performed and examination of any reports and films was performed. Grafts were graded as patent, luminal irregularity, or occluded. Each sequential graft was counted separately. Between September 1993 and December 2008, 13,926 patients underwent isolated coronary artery bypass grafting and 3248 patients had at least one radial artery graft used as a conduit. Catheterizations were performed at a mean of 7.4 ± 3.8 years (range, 3 days to 14.4 years) on 372 radial artery grafts (103 free and 269 T) in 215 patients. Kaplan-Meier freedom from occlusion for radial free and T grafts at 1 and 10 years was 97.1% and 75.4% and 99.6% and 62.9%, respectively (P=0.146 free versus T). Kaplan-Meier survival to 15 years was not statistically different between free and T graft patients (P=0.5). CONCLUSIONS: In 215 patients with postoperative catheterization after coronary artery bypass grafting with a radial artery graft, radial free and T grafts had similar and acceptable long-term patency to support their use as a coronary artery bypass graft conduit.

Trends in the indications and survival in pediatric heart transplants: a 24-year single-center experience in 307 patients.

BACKGROUND: Heart transplantation is the only viable treatment for children with end-stage heart failure due to congenital heart disease (CHD) or cardiomyopathy. This study reviewed the trends in the indications for transplant and survival after transplant during the past 24 years. METHODS: A retrospective review was performed of the 307 heart transplants performed at our center since 1986. To analyze the trends in the indications for transplant as well as operative death and late-survival, the data were divided into three periods in 8-year increments: 1986 to 1993 (50 patients), 1994 to 2001 (116 patients), and 2002 to 2009 (141 patients). RESULTS: The indications for transplantation were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 173 with CHD, 139 (80%) had single-ventricle (SV) anomalies. In the CHD group, transplantation for failed SV palliation, including Fontan procedure, became the predominant indication in the last 8-year interval of our program. Survival after transplant was the best in patients with cardiomyopathy and the worst in patients with failed palliations for SV anomalies, including failed Fontan procedures. CONCLUSIONS: Transplantation for heart failure related to failed SV palliation has become the most common indication for patients with CHD. The high-risk nature of these transplants will have significant implications for heart transplant programs as more infants with SV anomalies survive palliative procedures performed during infancy.

Cox-Maze IV results for patients with lone atrial fibrillation versus concomitant mitral disease.

BACKGROUND: This study compared Cox-Maze IV (CMIV) outcomes for the treatment of atrial fibrillation (AF) in patients with lone AF vs those with AF and mitral valve (MV) disease. METHODS: Since 2002, 200 patients have undergone a CMIV procedure for lone AF (n=101) or concomitantly with MV operations (n=99). Preoperative, perioperative, and late outcomes between these groups were compared. Data were collected prospectively and reported at 3, 6, and 12 months. RESULTS: Lone AF patients had AF of longer duration; patients with AF and MV disease were older, with larger left atria and worse New York Heart Association classification (p<0.05). Operative mortality (1% vs 4%, p>0.05, respectively) was similar between both groups. Perioperative atrial tachyarrhythmias were more prevalent in patients with concomitant MV operations (57% vs 41%, p=0.03); however, freedom from AF and antiarrhythmics was similar for both groups at 12 months (76% and 77%). The only predictor for atrial tachyarrhythmia recurrence or arrhythmic drug dependence was failure to isolate the posterior left atrium (p<0.01). CONCLUSIONS: Patients with AF and MV disease have distinct comorbidities compared with patients with lone AF. However, the CMIV is safe and effective in both groups and should be considered for patients with AF undergoing MV operations. Patients with MV disease had more atrial tachyarrhythmias at 3 months, but freedom from AF and antiarrhythmics was similar to patients with lone AF at 1 year. The posterior left atrium should be isolated in every patient, because this was the only predictor for failure of the CMIV for either group.

Impact of anastomotic techniques on airway complications after lung transplant.

BACKGROUND: Airway complications are a source of morbidity and expense after lung transplant. Posttransplant stenosis can occur when the donor bronchus is rendered ischemic and is dependent upon collateral flow from the pulmonary capillary system. By shortening the donor bronchus, the tissue at risk for ischemia is reduced. In an effort to reduce airway complications, one surgeon at our institution began dividing the donor bronchus at the lobar carina. METHODS: This is a retrospective analysis of all transplanted patients over the 2-year period before and after the institution of the technique change. To adjust for covariates, we performed a propensity score analysis. Outcome endpoints were postoperative airway complications, specifically, the need for therapeutic bronchoscopy, dilation, stenting, or retransplant. RESULTS: After instituting the practice of dividing the bronchus at the lobar carina, the incidence of airway complication for the principle surgeon decreased from 13.2% (7 of 53) to 2.1% (1 of 48), resulting in an improved freedom from airway complication for that surgeon. Compared with all transplants performed during this period, the modified anastomosis resulted in fewer airway complications: 2.1% (1 of 48) versus 8.2% (19 of 231). The propensity analysis matched the 48 patients who received the modified anastomosis with 48 patients who received the standard two ring length anastomosis by surgical colleagues. The modified anastomosis group had fewer required interventions for airway complications and had significantly better freedom from airway complication when followed over time. CONCLUSIONS: Decreasing the amount of potentially ischemic tissue implanted from the donor bronchus can reduce posttransplant airway complications.

Single-lung transplantation in the setting of aborted bilateral lung transplantation.

Background. The outcome of patients undergoing a single-lung transplant in the setting of an aborted bilateral lung transplant is unclear. Methods. A retrospective review of single lung transplants at an institutional program. Results. Of the 543 lung transplants performed over the last 10 years, 31 (5.7%) were single-lung transplants. Nineteen of 31 (61%) were planned single-lung transplants, while 12/31 (39%) were intraoperatively aborted, double lung transplants converted to single-lung transplants. The aborted and planned groups were similar in age, lung allocation score and NYHA status. The reasons for aborted double lung transplantation were cardiac/hemodynamic instability 4/12 (33%), difficult pneumonectomy 3/12 (25%), size mismatch 4/12(33%), and technical issues 1/12 (8%). The aborted group had higher CPB utilization (5/12 versus 1/19, P = .02), similar ischemic times (260 versus 234 min) and similar incidence of grade 3 primary graft dysfunction (6/12 versus 3/19, P = .13). ECMO was required for graft dysfunction in 2 patients in the aborted group. The one and two-year survival was 84% and 79% in the planned group and 62% and 52% in the aborted group, respectively. Conclusions. Patients undergoing single-lung transplantation in the setting of an aborted bilateral lung transplant may be at a higher risk of worse outcomes.

Retrograde jejunogastric decompression after esophagectomy is superior to nasogastric drainage.

BACKGROUND: Nasogastric tubes (NG) are commonly used for maintaining conduit decompression after esophagectomy. We investigated the use of retrograde tube gastrostomy (RG) after esophagectomy. METHODS: Patients underwent either NG or RG placement for postoperative conduit decompression. Both tubes were maintained on low continuous suction. RESULTS: Between 2000 and 2008, 306 patients underwent esophagectomy with reconstruction. One hundred ninety-three patients underwent NG and 113 underwent RG placement. The 2 groups were comparable in age, gender, tumor stage, and smoking status. Patients in the NG group were more likely to have received neoadjuvant therapy and to have a thoracotomy for esophagectomy. The incidence of respiratory complications was lower in the retrograde group compared with the NG group: Pneumonia, 9 of 113(8.0%) vs 50 of 193 (25.9%), p<0.001; respiratory failure requiring bronchoscopy or reintubation, 12 of 113 (10.8%) vs 46 of 193 (23.8%), p=0.004; aspiration, 4 of 113 (3.5%) vs 20 of 193 (10.4%), p=0.045. The incidence of cardiac dysrhythmias was also lower in the retrograde group (18 of 113 [15.9%] vs 69 of 193 [35.8%], p<0.001). The incidence of wound complications, myocardial infarction, stroke, and conduit necrosis-anastomotic leak was similar between groups. In a multivariate regression model an NG tube was the strongest predictor for postoperative pneumonia (odds ratio 3.27, 95% confidence interval 1.50 to 7.12). The other predictors were prior chest surgery, smoking, and thoracotomy incision. There were 4 minor complications related to the retrograde tube (wound infection n=1, broken tube requiring endoscopy n=2, tube caught in anastomosis detected intraoperatively n=1). CONCLUSIONS: Retrograde gastrostomy decompression of the conduit after esophagectomy is effective and diminishes complications compared with NG tube drainage.

Absence of deterioration of vascular function of the donor limb at late follow-up after radial artery harvesting.

OBJECTIVE: Radial artery harvesting has been questioned because of purported long-term circulatory consequences. Previous midterm Doppler ultrasonographic results are inconsistent regarding ulnar arterial effects. Flow-mediated vasodilatation more sensitively measures response to shear stress as index of arterial reactivity and function. METHODS: We contacted 231 patients who had undergone radial artery harvesting at least 10 years previously (mean follow-up, 12.9 ± 0.8 years). Subcohort of 25 volunteers (mean age, 69.2 ± 8.4 years) underwent ultrasonographic evaluation of ipsilateral (harvest) and contralateral (control) ulnar arteries. Flow-mediated vasodilatation compared changes in ulnar arterial diameters before and after occlusion. RESULTS: In subcohort, peak systolic velocity of harvest ulnar artery was 0.82 ± 0.15 m/s, versus 0.63 ± 0.23 m/s on control side (P < .001), with no differences in intimomedial thickness (P = .763) or presence of atherosclerotic plaques (P = .364). Baseline diameter of harvest ulnar artery was 3.0 ± 0.5 mm, versus 2.7 ± 0.6 mm on control side (P = .007). Postocclusion diameter of harvest ulnar artery was 3.2 ± 0.5 mm, versus 2.9 ± 0.6 mm on control side (P = .001). No differences were seen in preocclusion and postocclusion absolute and percentage changes in ulnar arterial diameter (Table 1). CONCLUSIONS: Despite increased shear stress, no deterioration in either ulnar arterial structure or functional reactivity was measured by flow-mediated vasodilatation more than 10 years after radial artery harvesting. With appropriate preoperative evaluation, radial arterial grafting for coronary artery bypass grafting is not associated with long-term donor limb vascular insufficiency.