Assessing the Fit of N95 Filtering Facepiece Respirators Fitted with an Ear Loop Strap System: A Pilot Study.

Throughout the COVID-19 pandemic, hundreds of millions of people worldwide have become new users of respiratory protective devices. Facemasks and KN95 respirators utilizing an ear loop straps system (ELSS) have recently become popular among occupational and non-occupational populations. Part of this popularity is due to the ease of wearability as compared with traditional devices utilizing two headbands, one worn over the head and the other behind the neck-a universal strap system used in NIOSH-certified N95 filtering facepiece respirators (FFRs). Some users convert the two-strap configuration to an adjustable ELSS. The first objective of this pilot study was to quantitatively characterize how such a conversion impacts the respirator fit. Additionally, a novel faceseal (NFS) technology, which has been previously demonstrated to enhance the fit of N95 FFRs, was deployed to modify the ELSS-converted N95 FFRs. The second objective of this study was to quantify the fit improvement that results from adding the NFS to the ELSS. The study was conducted by performing the Occupational Safety and Health Administration (OSHA)-approved quantitative fit testing (QNFT) on 16 human subjects featuring different facial shapes and dimensions. Three models of cup-shaped N95 FFRs were tested in three versions: the standard version with manufacturer's strap system, the ELSS-converted, and the ELSS-converted version modified by adding the NFS. QNFT demonstrated that the fit of an N95 FFR featuring the traditional/standard headbands strap system is negatively impacted when this system is converted to an ELSS. The fit of an ELSS-converted respirator can be significantly improved by the addition of the NFS. We found that the FFR model and the strap system version are significant factors affecting the QNFT-determined respirator fit factor (FF), as well as the OSHA QNFT pass rate (FF ≥100). The findings suggest that the current NFS, if further improved, has a potential for developing a 'universally fitting' ELSS-equipped N95 FFR that can be used by the general public, the vast majority of whom do not have access to OSHA fit requirements.

Surgical Smoke Simulation Study: Physical Characterization and Respiratory Protection.

Exposure of operating room (OR) personnel to surgical smoke, a unique aerosol generated from the common use of electrocautery during surgical procedures, is an increasing health risk concern. The main objective of this simulation study was to characterize the surgical smoke exposure in terms of the particle number concentration and size distribution in a human breathing zone. Additionally, the performance of respiratory protective devices designed for ORs was examined using two commercially available N95 facepiece filtering respirators (FFRs) as well as the same FFRs modified with new faceseal technology. The tests were conducted in an OR-simulating exposure chamber with the surgical smoke generated by electrocautery equipment applied to animal tissue and measured in the breathing zone with four aerosol spectrometers. The simulated workplace protection factor of each tested respirator was determined for ten subjects by measuring the total aerosol concentrations inside and outside of a respirator. The peak of the particle size distribution was in a range of 60-150 nm. The concentration of particles generated during the simulated surgical procedure significantly exceeded the background concentration under all tested air exchange conditions. The data suggest that wearing N95 filtering facepiece respirators significantly decreased the human exposure to surgical smoke. The new faceseal technology provided significantly higher respiratory protection than the commercial N95 FFRs.

Performance of Facepiece Respirators and Surgical Masks Against Surgical Smoke: Simulated Workplace Protection Factor Study.

OBJECTIVE: Surgical smoke generated during electrocautery contains toxins which may cause adverse health effects to operating room (OR) personnel. The objective of this study was to investigate the performance of surgical masks (SMs), which are routinely used in ORs, more efficient N95 surgical mask respirator (SMRs) and N100 filtering facepiece respirator (FFRs), against surgical smoke. METHODS: Ten subjects were recruited to perform surgical dissections on animal tissue in a simulated OR chamber, using a standard electrocautery device, generating surgical smoke. Six respiratory protective devices (RPDs) were tested: two SMs, two SMRs, and two N100 FFRs [including a newly developed faceseal (FS) prototype]. Fit testing was conducted before the experiment. Each subject was then exposed to the surgical smoke while wearing an RPD under the tests. Concentrations inside (C in) and outside (C out) of the RPD were measured by a particle size spectrometer. The simulated workplace protection factor (SWPF) was determined by the ratio of C out and C in for each RPD-wearing subject. RESULTS: For the SMs, the geometric means of SWPFtotal (based on the total aerosol concentration) were 1.49 and 1.76, indicating minimal protection. The SWPFtotal values of the SMRs and N100 FFRs were significantly higher than those of the SMs: for the two SMRs, the SWPFtotal were 208 and 263; for the two N100s, the SWPFtotal values were 1,089 and 2,199. No significant difference was observed between either the two SMs or the two SMRs. The SWPFtotal for the novel FS prototype N100 FFR was significantly higher than the conventional N100 FFR. The correlation between SWPFtotal and fit factor (FF) determined for two N95 SMRs was not significant. CONCLUSIONS: SMs do not provide measurable protection against surgical smoke. SMRs offer considerably improved protection versus SMs, while the N100 FFRs showed significant improvement over the SMRs. The FS prototype offered a higher level of protection than the standard N100 FFR, due to a tighter seal. While we acknowledge that conventional N100 FFRs (equipped with exhalation valves) are not practical for human OR use, the results obtained with the FS prototype demonstrate the potential of the new FS technology for implementation on various types of respirators.

Thoracic multidisciplinary tumor board routinely impacts therapeutic plans in patients with lung and esophageal cancer: a prospective cohort study.

BACKGROUND: National and subspecialty guidelines for lung and esophageal cancers recommend treatment decisions to be made in a multidisciplinary tumor board (MTB). This study prospectively analyzes the actual impact of presentation at the thoracic tumor board on decision making in thoracic cancer cases. METHODS: During the electronic submission process for presentation at MTB managing physicians documented their current treatment plan. The initial treatment plan was compared with the MTB final recommendation. Patient demographics, physician's proposed treatment plan, MTB recommendation, and documentation of application of MTB recommendations were prospectively recorded in an Institutional Review Board approved database. RESULTS: Between June 2010 and December 2012, 185 patients with esophageal and 294 patients with lung cancer were presented at the MTB. One hundred sixty-six patients were presented on more than 1 occasion, resulting in 724 assessments of 479 patients. In 48 esophageal cancer patients (26%) and 118 lung cancer patients (40%) MTB recommendations differed from the initial treatment plan. Overall, a differing MTB recommendation from the primary treatment plan occurred in 330 of 724 case presentations (46%). The MTB recommendations changed treatment plans in 40% and staging and assessment plans in 60% of patients. Follow-up in a cohort of 249 patients confirmed that MTB recommendations were followed in 97% of cases. CONCLUSIONS: This study validates the impact of the thoracic MTB. Recommendations will differ from the managing providers' initial plan in 26% to 40% of cases. However, MTB recommendations can be successfully initiated in the majority of patients. Complex thoracic cancer patients will benefit from multidisciplinary review and should ideally be presented at tumor board.

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.

BACKGROUND: Adoption ofa preprocedural pause (PPP) associated with a checklist and a team briefing has been shown to improve teamwork function in operating rooms (ORs) and has resulted in improved outcomes. The format of the World Health Organization Safe Surgery Saves Lives checklist has been used as a template for a PPP. Performing a PPP, described as a "time-out," is one of the three principal components, along with a preprocedure verification process and marking the procedure site, of the Joint Commission's Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery. However, if the surgeon alone leads the pause, its effectiveness may be decreased by lack of input from other operating team members. METHODS: In this study, the PPP was assessed to measure participation and input from operating team members. On the basis of low participation levels, the pause was modified to include an attestation from each member of the team. RESULTS: Preliminary analysis of our surgeon-led pause revealed only 54% completion of all items, which increased to 97% after the intervention. With the new format, operating team members stopped for the pause in 96% of cases, compared with 78% before the change. Operating team members introduced themselves in 94% of cases, compared with 44% before the change. Follow-up analysis showed sustained performance at 18 months after implementation. CONCLUSIONS: A preprocedural checklist format in which each member of the operating team provides a personal attestation can improve pause compliance and may contribute to improvements in the culture of teamwork within an OR. Successful online implementation of a PPP, which includes participation by all operating team members, requires little or no additional expense and only minimal formal coaching outside working situations.

Iron-deficiency anemia is a common presenting issue with giant paraesophageal hernia and resolves following repair.

BACKGROUND: A significant percentage of patients with paraesophageal hernia (PEH) will have a co-existing diagnosis of iron-deficiency anemia which will resolve following surgical repair. METHODS: Between 2000 and 2010, 270 patients underwent operative repair of PEH. Of this group, 123 patients (45.6 %) reported a preexisting diagnosis of iron-deficiency anemia. The study group consisted of 77 patients with a documented preoperative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up level at least 3 months following surgery. RESULTS: Of the 77 patients included, 72 underwent elective repair, median age was 75 (39-91) years, and 65 % were female. Cameron erosions were identified preoperatively in 32 %. Mean preoperative hemoglobin was 9.6 (4.4-13.6) g/dl and postoperative hemoglobin was 13.2 (10.7-17) g/dl at 3-12 months and 13.6 (9.7-17.2) g/dl at more than 1 year. Ninety percent of patients had a rise in postoperative hemoglobin level by at least 1 g/dL. Anemia resolved in 55 (71 %) patients, more often in women and younger patients (<70 years). Twenty-nine of 40 (73 %) patients on iron therapy discontinued this postoperatively. CONCLUSION: A significant number of patients who present with giant PEH will present with iron-deficiency anemia. Elective repair will result in resolution of the anemia in more than 70 % of patients. PEH is underappreciated as a source of iron-deficiency anemia, and appropriate patients should be considered for elective repair.

Novel multimodality endoscopic closure of postoperative esophageal fistula.

INTRODUCTION: Esophageal fistula following esophagectomy is associated with significant morbidity and mortality. PRESENTATION OF CASE: We present the case of a 71-year-old man who underwent salvage Ivor-Lewis esophagectomy, following definitive chemoradiotherapy 1 year previously. On postoperative day 9 the patient complained of chest pain, and a CT scan demonstrated extravasation of oral contrast from the gastric conduit into the right chest. A right chest drain and fully covered esophageal stent were placed at this time. Despite these measures, after 8 weeks, the esophageal fistula persisted. Ultimately, fistula closure was achieved using an interventional radiology-guided, endoscopically placed over-the-scope clip (OTSC). The patient had no further complications and was well at 3 months follow-up. DISCUSSION: The case reported herein describes this novel, combined-modality approach to esophageal fistula closure. CONCLUSION: This case report demonstrates a novel, minimally invasive, multidisciplinary approach to the closure of a post-esophagectomy anastamotic leak.

Clinical ramifications of giant paraesophageal hernias are underappreciated: making the case for routine surgical repair.

BACKGROUND: We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia. METHODS: Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms. RESULTS: The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n=10), III (n=206), and IV (n=54), and the percent intrathoracic stomach was less than 50% (n=33), 50% to 74% (n=86), 75% to 99% (n=55), and 100% (n=96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p=0.005) and dyspnea (type IV; p=0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p=0.04); higher percent intrathoracic stomach with early satiety (p=0.02), decreased meal size (p=0.007), and dyspnea (p<0.001); and 50% to 74% intrathoracic stomach with anemia (p=0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%). CONCLUSIONS: Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair.

Repair of giant paraesophageal hernias routinely produces improvement in respiratory function.

OBJECTIVE: Assessment of the clinical impact of giant paraesophageal hernias have historically focused on upper gastrointestinal symptoms. This study assesses the effect of paraesophageal hernia repair on respiratory function. METHODS: All patients undergoing repair of giant paraesophageal hernia were prospectively entered into a database approved by the institutional review board. Patients had symptoms documented preoperatively, including dyspnea. Pulmonary function tests (PFTs) were done preoperatively and repeated a median of 106 days after repair (range, 16-660 days). RESULTS: Preoperative and postoperative PFTs were obtained in 120 unselected patients treated for paraesophageal hernia between 2000 and 2010. Patients' median age was 74 years (range, 45-91 years), 74 (62%) were female, and median body mass index was 28.0 (range, 16.8-46.6). Median length of stay was 4 days (range, 3-10 days), and perioperative mortality was zero. Hernias were classified as type II in 3 (3%) patients, III in 92 (77%), and IV in 25 (21%). Percent of intrathoracic stomach was assigned from preoperative contrast studies and grouped as less than 50% (n = 6; 5%), 50% to 74% (n = 35; 29%), 75% to 99% (n = 29; 24%), and 100% (n = 50; 42%). Preoperative symptoms included heartburn 71 (59%), early satiety 65 (54%), dyspnea 63 (52%), chest pain 48 (40%), dysphagia 56 (47%), regurgitation 47 (39%), and anemia 44 (37%). PFTs significantly improved after paraesophageal hernia repair (mean volume change, percent reference change): forced vital capacity +0.30 L,+10.3%pred; FEV(1) +0.23 L,+10.4%pred (all P < .001); diffusion capacity of the lung for carbon monoxide +0.58 mL · mm Hg(-1) · min(-1) (P = .004), and +2.9%pred (P = .002). Greater improvements were documented in older patients with significant subjective respiratory symptoms and higher percent of intrathoracic stomach (P < .01). CONCLUSIONS: Paraesophageal hernia has a significant effect on respiratory function, which is largely underappreciated. This study demonstrates that these repairs can be done safely and supports routine consideration for elective repair; older patients with borderline respiratory function may achieve substantial improvements in their respiratory status and quality of life.

Evolving management strategies in esophageal perforation: surgeons using nonoperative techniques to improve outcomes.

BACKGROUND: Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes. STUDY DESIGN: Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality. RESULTS: Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative. CONCLUSIONS: Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.

Template for success: using a resident-designed sign-out template in the handover of patient care.

OBJECTIVE: Report our implementation of a standardized handover process in a general surgery residency program. DESIGN: The standardized handover process, sign-out template, method of implementation, and continuous quality improvement process were designed by general surgery residents with support of faculty and senior hospital administration using standard work principles and business models of the Virginia Mason Production System and the Toyota Production System. SETTING: Nonprofit, tertiary referral teaching hospital. PARTICIPANTS: General surgery residents, residency faculty, patient care providers, and hospital administration. RESULTS: After instruction in quality improvement initiatives, a team of general surgery residents designed a sign-out process using an electronic template and standard procedures. The initial implementation phase resulted in 73% compliance. Using resident-driven continuous quality improvement processes, real-time feedback enabled residents to modify and improve this process, eventually attaining 100% compliance and acceptance by residents. CONCLUSIONS: The creation of a standardized template and protocol for patient handovers might eliminate communication failures. Encouraging residents to participate in this process can establish the groundwork for successful implementation of a standardized handover process. Integrating a continuous quality-improvement process into such an initiative can promote active participation of busy general surgery residents and lead to successful implementation of standard procedures.

Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy.

OBJECTIVE: Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. METHODS: A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. RESULTS: Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100-400 ml) for the TH group and 216 ml (range 80-500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥ 10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p=0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p=0.01. CONCLUSION: This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.

Differential redox regulation of ORAI ion channels: a mechanism to tune cellular calcium signaling.

Reactive oxygen species (ROS) are involved in many physiological and pathophysiological cellular processes. We used lymphocytes, which are exposed to highly oxidizing environments during inflammation, to study the influence of ROS on cellular function. Calcium ion (Ca(2+)) influx through Ca(2+) release-activated Ca(2+) (CRAC) channels composed of proteins of the ORAI family is essential for the activation, proliferation, and differentiation of T lymphocytes, but whether and how ROS affect ORAI channel function have been unclear. Here, we combined Ca(2+) imaging, patch-clamp recordings, and measurements of cell proliferation and cytokine secretion to determine the effects of hydrogen peroxide (H(2)O(2)) on ORAI channel activity and human T helper lymphocyte (T(H) cell) function. ORAI1, but not ORAI3, channels were inhibited by oxidation by H(2)O(2). The differential redox sensitivity of ORAI1 and ORAI3 channels depended mainly on an extracellularly located reactive cysteine, which is absent in ORAI3. T(H) cells became progressively less redox-sensitive after differentiation into effector cells, a shift that would allow them to proliferate, differentiate, and secrete cytokines in oxidizing environments. The decreased redox sensitivity of effector T(H) cells correlated with increased expression of Orai3 and increased abundance of several cytosolic antioxidants. Knockdown of ORAI3 with small-interfering RNA rendered effector T(H) cells more redox-sensitive. The differential expression of Orai isoforms between naïve and effector T(H) cells may tune cellular responses under oxidative stress.

Assessment of criteria and clinical significance of circumferential resection margins in esophageal cancer.

OBJECTIVE: To assess the clinical significance of circumferential resection margins according to current criteria of the College of American Pathologists (CAP) and the Royal College of Pathology (RCP) in esophageal and esophagogastric cancer. DESIGN: Prospective study. SETTING: Single-surgeon database. PATIENTS: One hundred thirty-five patients (mean age, 64 years) with T3 tumors who underwent esophageal resection for cancer between 1991 and 2006. Main Outcome Measure Resection margins criteria and survival. RESULTS: Three hundred seventy-four consecutive patients were prospectively identified from an institutional review board-approved database between 1991 and 2006. All patients with T3 tumors (n = 135) had their original pathologic slides reassessed by a single gastrointestinal pathologist. Operative mortality was 0.7% and mean follow-up was 3.1 years. Follow-up was complete in 81% of patients. Positive margins were identified in 16 cases in the CAP group vs 83 cases in the RCP group. Five-year Kaplan-Meier survival curves in the CAP group demonstrated a significant (P < .001) difference in survival, whereas the RCP group showed no difference (P = .20). In comparisons of negative vs positive margins, respectively, median survival in the CAP group (29.8 months [95% confidence interval (CI), 22.7-36.9] vs 8.33 months [95% CI, 4.4-12.3]) was significantly different from the RCP group (28.47 months [95% CI, 19.7-37.2] vs 22.23 months [95% CI, 13.6-30.8]). At 60-month follow-up, the positive predictive value with respect to survival was 100% in the CAP group vs 81% in the RCP group. Univariate and multivariate analyses identified R1 margins in the CAP group and lymph node ratio as being directly linked to survival. CONCLUSIONS: Positive circumferential resection margins are prognostically important and the CAP criteria provide a more clinically meaningful assessment. Universal adoption of the CAP system can improve interpretation of international clinical trials and allow more accurate comparisons of outcomes.

Management of postthoracotomy pain: acute and chronic.

Given the discomfort of thoracic surgical incisions, thoracic surgeons must understand and use contemporary multimodality pain treatments. Acute postthoracotomy pain not only causes psychologic distress to the patient but also has detrimental effects on pulmonary function and postoperative mobility, leading to increased morbidity. By choosing the most appropriate and least traumatic surgical incision, adhering to meticulous surgical techniques, and avoiding intercostal nerve injury or rib fractures, surgeons can minimize postoperative pain. Aggressive perioperative and postoperative pain management is best accomplished with use of an epidural anesthetic and covering breakthrough pain with an IV-PCA. Alternatively, an infusion system for continuous administration of local anesthetics directly in the subpleural plane, posterior to the intercostal incision, also provides excellent pain control. Again, use of an IV-PCA as adjuvant therapy is recommended. With careful planning, severe pain and its negative impact on thoracic surgical patients can be prevented.

Sublobar resection with brachytherapy versus lobectomy for stage Ib nonsmall cell lung cancer.

BACKGROUND: We have previously shown that intraoperative brachytherapy decreases the local recurrences associated with sublobar resections for small stage Ia nonsmall-cell lung cancer (NSCLC). In this report, we present the outcomes of sublobar resection with brachytherapy compared with lobectomy in patients with stage Ib tumors. METHODS: We retrospectively reviewed 167 stage Ib NSCLC patients: 126 underwent lobectomy and 41 sublobar resection with (125)I brachytherapy over the resection staple line. Endpoints were perioperative outcomes, incidence of recurrence, and disease-free and overall survival. RESULTS: Patients undergoing sublobar resections had significantly worse preoperative pulmonary function. Hospital mortality, nonfatal complications, and median length of stay were similar in the two groups. Median follow-up was 25.1 months. Local recurrence in sublobar resection patients was 2 of 41 (4.8%), similar to the lobectomy group: 4 of 126 (3.2%; p = 0.6). At 4 years, both groups had equivalent disease-free survival (sublobar group, 43.0%; median, 37.7 months; and lobectomy group, 42.8%; median 41.8 months, p = 0.57) and overall survival (sublobar group, 54.1%; median, 50.2 months; and lobectomy group, 51.8%; median, 56.9 months; p = 0.38). CONCLUSIONS: Sublobar resection with brachytherapy reduced local recurrence rates to the equivalent of lobectomy in patients with stage Ib NSCLC, and resulted in similar perioperative outcomes and disease-free and overall survival, despite being used in patients with compromised lung function. We recommend the addition of intraoperative brachytherapy to sublobar resections in stage Ib patients who cannot tolerate a lobectomy.

Minimal adhesions to ePTFE mesh after laparoscopic ventral incisional hernia repair: reoperative findings in 65 cases.

OBJECTIVES: Laparoscopic ventral incisional hernia repair involves intraabdominal placement of a synthetic mesh, and the possibility of formation of severe visceral adhesions to the prosthesis is a principal concern. Little clinical information based on reoperative findings is available about adhesions to biomaterials placed intraabdominally. We conducted a multiinstitutional study of adhesions to implanted expanded polytetrafluoroethylene (ePTFE) mesh at reoperation in patients who had previously undergone laparoscopic incisional hernia repair done with the same mesh implantation technique. METHODS: Nine surgeons retrospectively assessed the severity of adhesions to ePTFE mesh at reoperation in 65 patients. For each case, adhesions were assigned a score of 0 to 3, with 0 indicating no adhesions and 3 severe adhesions. RESULTS: The mean time from mesh implantation to reoperation was 420 days (range, 2 to 1739 days). No adhesions were observed in 15 cases. Forty-four cases received an adhesion score of 1, and 6 cases a score of 2; no scores of 3 were assigned. Thus, 59 patients (91%) had either no or filmy, avascular adhesions. No enterotomies occurred during adhesiolysis. CONCLUSIONS: In this large series of reoperations after laparoscopic incisional hernia repair, no or minimal formation of adhesions to implanted ePTFE mesh was observed in 91% of cases, and no severe cohesive adhesions were found. Comparative analyses of newer materials based on clinical reoperative findings are warranted to assess the safety of intraabdominally placed meshes.