Outcomes and predictors of survival for tracheal cancer.

INTRODUCTION: Primary tracheal cancer is uncommon, with poor survival. While surgical resection is the mainstay of therapy, the role of chemotherapy and radiation is poorly defined. We aimed to study the impact of treatment modalities on survival. METHODS: Patients with primary tracheal cancer were identified from the National Cancer Database over 12 years, 2004-2015. Patient characteristics, tumor characteristics, treatment modalities, and survival were recorded. Factors associated with survival were assessed using Cox Regression. RESULTS: Of the 1726 patients identified, 59% were male, 83% White race, 62% had a comorbidity index of zero, median age 64 years, median tumor size 2.7 cm, and median survival was 28.5 months (89 months for patients undergoing surgical resection). Cox Regression for all patients found adenoid cystic carcinoma (ACC) (p < 0.001), radiation (p < 0.001), and surgical resection (p < 0.001) to be associated with improved survival, while increasing age (p < 0.001) decreased survival. For patients receiving resection, ACC (p < 0.001) was associated with improved survival, while increasing age (p < 0.001) and positive margins (p = 0.002) were associated with worse survival. For R0 resections, ACC (p < 0.001) was associated with improved survival, while increasing age (p < 0.001) decreased survival, with chemotherapy and radiation having no impact. For R1/2 resections, ACC (p < 0.001) and radiation (p < 0.001) were associated with improved survival, while increasing age (p < 0.001) decreased survival, with chemotherapy having no impact on survival. CONCLUSIONS: Primary tracheal cancer is highly lethal, with surgical resection leading to the best chance of survival. For patients undergoing resection, radiation provided survival benefits for R1/2 but not R0, while chemotherapy did not impact survival regardless of margin status.

Surgeon Quality and Patient Survival After Resection for Non-Small-Cell Lung Cancer.

PURPOSE: The quality and outcomes of curative-intent lung cancer surgery vary in populations. Surgeons are key drivers of surgical quality. We examined the association between surgeon-level intermediate outcomes differences, patient survival differences, and potential mitigation by processes of care. PATIENTS AND METHODS: Using a baseline population-based surgical resection cohort, we derived surgeon-level cut points for rates of positive margins, nonexamination of lymph nodes, nonexamination of mediastinal lymph nodes, and wedge resections. Applying the baseline cut points to a subsequent cohort from the same population-based data set, we assign surgeons into three performance categories in reference to each metric: 1 (<25th percentile), 2 (25th-75th percentile), and 3 (>75th percentile). The sum of performance scores created three surgeon quality tiers: 1 (4-6, low), 2 (7-9, intermediate), and 3 (10-12, high). We used chi-squared, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests to compare patient characteristics between the baseline and subsequent cohorts and across surgeon tiers. We applied Cox proportional hazards models to examine the association between patient survival and surgeon performance tier, sequentially adjusting for clinical stage, patient characteristics, and four specific processes. RESULTS: From 2009 to 2021, 39 surgeons performed 4,082 resections across the baseline and subsequent cohorts. Among 31 subsequent cohort surgeons, five were tier 1, five were tier 2, and 21 were tier 3. Tier 1 and 2 surgeons had significantly worse outcomes than tier 3 surgeons (hazard ratio [HR], 1.37; 95% CI, 1.10 to 1.72 and 1.19; 95% CI, 1.00 to 1.43, respectively). Adjustment for specific processes mitigated the surgeon-tiered survival differences, with adjusted HRs of 1.02 (95% CI, 0.8 to 1.3) and 0.93 (95% CI, 0.7 to 1.25), respectively. CONCLUSION: Readily accessible intermediate outcomes metrics can be used to stratify surgeon performance for targeted process improvement, potentially reducing patient survival disparities.

Optimal time to thoracoscopy for trauma patients with retained hemothorax.

BACKGROUND: Retained hemothorax remains a common problem after thoracic trauma with associated morbidity and prolonged hospitalizations. The goal of this study was to examine the impact of time to video assisted thoracoscopic surgery (VATS) on pulmonary morbidity using a large, national data set. METHODS: Patients undergoing VATS for retained hemothorax within the first 14 days postinjury were identified from the Trauma Quality Improvement Program database over 5 years, ending in 2016. Demographics, mechanism, severity of injury, severity of shock, time to VATS, pulmonary morbidity, and mortality were recorded. Multivariable logistic regression analysis was performed to determine independent predictors of pulmonary morbidity. Youden's index was then used to identify the optimal time to VATS. RESULTS: From the Trauma Quality Improvement Program database, 3,546 patients were identified. Of these, 2,355 (66%) suffered blunt injury. The majority were male (81%) with a median age and Injury Severity Score of 46 and 16, respectively. The median time to VATS was 134 hours. Both pulmonary morbidity (13 vs 17%, P = .004) and hospital length of stay (9 vs 12 days, P < .0001) were significantly reduced in patients undergoing VATS before 3.9 days. Multivariable logistic regression identified VATS during the first 7 days as the only modifiable risk factor significantly associated with reduced pulmonary morbidity (odds ratio 0.52; 95% confidence interval 0.43-0.63, P < .0001). CONCLUSION: Patients undergoing VATS for retained hemothorax have significant morbidity and prolonged length of stay. VATS within the first week of admission results in fewer pulmonary complications and shorter length of stay. In fact, the optimal time to VATS was identified as 3.9 days and was the only modifiable risk factor associated with decreased pulmonary morbidity.

Delayed Endovascular Repair With Procedural Anticoagulation: A Safe Strategy for Blunt Aortic Injury.

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma. The purposes of this study were to identify predictors of mortality for BAI and to examine the impact of procedural heparinization during thoracic endovascular aortic repair (TEVAR) on neurologic outcomes in patients with BAI/TBI. METHODS: Patients with BAI were identified over an 8 year period. Age, gender, severity of injury and shock, time to TEVAR, morbidity, and mortality were recorded and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of mortality. Youden's index determined optimal time to TEVAR. RESULTS: A total of 129 patients were identified. The majority (74%) were male with a median age and injury severity score (ISS) of 40 years and 29, respectively. Of these, 26 (20%) had a concomitant TBI. Patients with BAI/TBI had higher injury burden at presentation (ISS 37 vs. 29, P = 0.002; Glasgow Coma Scale [GCS] 6 vs. 15, P < 0.0001), underwent fewer TEVAR procedures (31 vs. 53%, P = 0.039), and suffered increased mortality (39 vs. 16%, P = 0.009). All TEVARs had procedural anticoagulation, including patients with TBI, without change in neurologic function. The optimal time to TEVAR was 14.8 hr. Mortality increased in TEVAR patients before 14.8 hr (8.7 vs. 0%, P = 0.210). MLR identified TEVAR as the only modifiable factor that reduced mortality (odds ratio 0.11; 95% confidence interval 0.03-0.45, P = 0.002). CONCLUSIONS: TEVAR use was identified as the only modifiable predictor of reduced mortality in patients with BAI. Delayed TEVAR with the use of procedural heparin provides a safe option regardless of TBI with improved survival and no difference in discharge neurologic function.

Pericardial injury after motor vehicle accident.

Pericardial rupture is rare after blunt thoracic trauma and is associated with significant mortality. Mesh repair is recommended to prevent cardiac herniation and strangulation.

Pulmonary Artery and Intercostal Artery Pseudoaneurysms After Penetrating Injury.

Traumatic pulmonary artery and intercostal artery pseudoaneurysms are rare pathologies that can occur after a penetrating injury. Most times, only 1 pseudoaneurysm needs to be addressed. Options for management include simple observation, endovascular intervention with coiling, embolization, and stenting, as well as surgical intervention ranging from ligation to pneumonectomy. We present the case of a 20-year-old man who developed multiple pulmonary artery pseudoaneurysms and an intercostal artery pseudoaneurysm after sustaining a single gunshot wound to the chest. After multiple episodes of bleeding from several pseudoaneurysms, the patient ultimately required a pneumonectomy.

Bedside Mediastinotomy for Tension Pneumomediastinum With Tamponade in COVID-19.

Tension pneumomediastinum is a rare but life-threatening cause of tamponade. Mechanical ventilation is a described source of tension pneumomediastinum. Here, we present a case of a 72-year-old man who developed cardiovascular collapse from tension pneumomediastinum in the setting of coronavirus disease 2019-related acute respiratory distress syndrome. We successfully performed bedside mediastinotomy and mediastinal tube placement under local anesthetic to alleviate his hemodynamic instability. Bedside mediastinotomy can be used to relieve tension pneumomediastinum in this setting.

Primary Aldosteronism: Diagnosis and Management.

Primary aldosteronism (PA) is an important and commonly unrecognized cause of secondary hypertension. Idiopathic hyperaldosteronism and aldosterone-producing adenomas account for more than 95% of PA and are characterized, respectively, by bilateral or unilateral involvement of the adrenal glands. When there is suspicion for the presence of PA, a plasma aldosterone to renin ratio should be obtained initially. Localization to determine adrenal gland involvement is done by imaging, with computerized tomography or magnetic resonance imaging. After imaging, adrenal vein sampling is done to establish treatment options. Patients with unilateral disease, who are good surgical candidates, are most appropriately managed with adrenalectomy. A biochemical cure is almost certain following adrenalectomy; however, only 30-50% of patients would show adequate blood pressure improvement. Patients with bilateral adrenal disease and those believed not to be surgical candidates are managed with mineralocorticoid antagonists.

Secondary abdominal compartment syndrome causing failure to wean from cardiopulmonary bypass.

The abdominal compartment syndrome has been associated with trauma or primary abdominal procedures. The secondary abdominal compartment syndrome which is not associated with a primary abdominal process is seen in burns and other clinical situations where aggressive fluid resuscitation is needed. This case report describes a secondary abdominal compartment syndrome that occurred during an elective coronary revascularization which resulted in an inability to wean from cardiopulmonary bypass (CPB). After a decompressive laparotomy was done, the patient was successfully weaned from bypass.

Acute pulmonary edema after pericardial drainage for cardiac tamponade.

Pericardial effusions with tamponade may present a clinical challenge in management for the cardiothoracic surgeon. We report a case of acute pulmonary edema secondary to the rapid release of a chronic traumatic pericardial effusion that resulted in the death of the patient.

Comparison of spinal cord protection utilizing left atrial-femoral with femoral-femoral bypass in patients with traumatic rupture of the aortic isthmus.

INTRODUCTION: Postoperative paraplegia remains a dreaded complication of repair of traumatic rupture of the aortic isthmus. Claims have been made that left atrial-femoral bypass provides better spinal cord protection. To test the hypothesis that left atrial-femoral bypass is better than femoral vein-to-femoral artery bypass in regard to postoperative paraplegia, we concurrently compared the two techniques. METHODS: We compared the occurrence of paraplegia in 18 patients whose ruptures were repaired utilizing left atrial-femoral bypass with 10,000 units of systemic heparin (group A) and 72 patients with femoral-femoral bypass with heparin 300 units/kg and an oxygenator (group B) operated on between January 1995 and July 2004. RESULTS: The mortality rate was 5.6% (5/90), with no statistical difference between the two groups. Postoperative paraplegia was present in three (16.7%) group A patients and five group B (6.9%) patients. However, the specific etiology of the neurologic defect was not clear, as one patient's paraplegia was transient following a period of cardiac arrest, and four others had had neurologic injuries prior to the aortic repair. Median aortic cross-clamp times were shorter in group A (34 minutes vs. 49 minutes). No patient required reexploration for bleeding, and no patient developed a graft infection. CONCLUSIONS: Paraplegia rates were higher in the left atrial-femoral group, but the difference was not statistically significant. This occurred despite the decreased cross-clamp times in this group. In patients undergoing repair of traumatic rupture of the aortic isthmus, left atrial-femoral bypass does not provide better spinal cord protection than femoral-femoral bypass.

Ruptured umbilical hernia in a case of alcoholic cirrhosis with massive ascites.

Umbilical hernias are common in patients with cirrhosis of the liver and ascites. However, spontaneous rupture of the hernia is not frequently seen. This is a serious complication and carries a high mortality. A search of the literature shows that patients have been managed both operatively and nonoperatively for this condition. We present a case of spontaneous rupture of an umbilical hernia in a patient with cirrhosis and ascites which was managed successfully with hernia repair.