Annals of thoracic surgery short reports最新文献

Background

Frailty is associated with increased perioperative morbidity and mortality. How thoracic surgeons recognize, measure, and mitigate frailty in their daily clinical practice is unknown. We administered a national survey to determine the current practices of thoracic surgeons managing frail patients.

Methods

A 144-question survey developed in collaboration with the University of Chicago Survey Lab was sent to CTSnet.org members who identified as general thoracic surgeons, practiced in the United States, and had publicly available emails. Responses were collected from August 12 to September 11, 2022. Both fully and partially (at least 20%) completed surveys were included in a descriptive statistical analysis.

Results

After 2796 surveys were administered, 342 surgeons responded. Surgeons were in practice a median of 23 years (range, 1-50 years) at academic (63.4% [187/295]) or community (36.6% [108/295]) centers. Most surgeons believed it important to assess frailty preoperatively (83.9% [287/342]), but only 28% (97/342) of surgeons performed routine frailty assessment. Barriers to routine frailty assessment included lack of tools (80.0% [32/40]), training (59.0% [23/39]), and staffing (56.4% [22/39]). Whereas most surgeons believed that frailty could be mitigated (72.2% [247/342]), only 49.5% (156/315) prescribed prehabilitation. Up to 78.7% (203/263) of surgeons would delay or cancel surgery for patient frailty, depending on disease cause.

Conclusions

Thoracic surgeons recognize that frailty is an established risk factor for perioperative morbidity and mortality; however, there is high variability in diagnosis and management of frailty. Guidelines are needed to establish best practices for screening and mitigation to optimally treat frail patients.

Azygos lobe is an uncommon anatomic variant that is widely recognized, but rarely associated with pneumothorax. We present a successful surgical management of a spontaneous pneumothorax resulting from rupture of a bulla in an incidentally discovered azygos lobe. The patient is a 73-year-old man who presented with the first-time occurrence of a spontaneous right pneumothorax. The patient did not tolerate nonoperative management and underwent a right thoracotomy with bullae resection in the azygos and right lower lobes for definitive management. Our treatment highlights several considerations during operative management of azygos lobe pathology.

Background

Organ procurement organizations coordinate organ donation through 2 distinct models of care: the conventional model, in which donors are managed at hospitals where brain death occurs, and the specialized donor care facility (SDCF) model, where brain dead donors are transferred to a freestanding facility. The aim of this study is to compare operating room efficiency for procurements between the SDCF and conventional models of care.

Methods

We performed a prospective analysis of operating room efficiency between thoracic donor procurement operations performed at a SDCF and other organ procurement organizations using the conventional model of care. Key domains of efficiency were chosen based on a literature review and expert panel consensus. Data were collected in real time over a 12-month period via direct observation and personnel interviews.

Results

Between January 1 and December 31, 2018, data were obtained from 54 procurement operations (n = 17 SDCF; n = 37 conventional). Donors in the 2 groups were similar in baseline characteristics. Procurements at the SDCF were performed with fewer nonsurgeon team members (2 vs 4, P < .001) without any difference in the organ yield. SDCF procurements more closely adhered to planned start times (6 vs 61 minute difference, P < .001), and a trend was observed for SDCF-based procurements to facilitate daytime transplant operations.

Conclusions

The SDCF model of donor care outperforms the conventional model in several important measures of operating room efficiency. These differences are likely to result in cost savings and improved healthcare provider satisfaction in the highly effort- and resource-intensive landscape of organ transplantation.

Inflammatory myofibroblastic tumor is a rare occurring benign tumor composed of myofibroblastic spindle cells. Lung inflammatory myofibroblastic tumor is difficult to diagnose and may mimic lung cancer or infectious etiology. Surgical intervention with final histopathologic confirmation remains the mainstay of diagnosis. We report an incidental finding of a pediatric case of lung inflammatory myofibroblastic tumor with clinical presentation, management, and outcomes at more than 2 years of follow-up at a tertiary care hospital in Saudi Arabia.

Congenital pulmonary airway malformations (CPAMs) are cystic lung lesions often detected prenatally. Resection is often recommended for potential recurrent infections and malignancy. This report describes a case of a 14-year-old female patient who presented with abdominal pain. A computed tomographic scan of the abdomen revealed a cystic lesion at the base of her right lung. Consequently, a computed tomographic arteriogram of the chest demonstrated a right lower lobe lesion concerning for type I CPAM. After thoracoscopic segmentectomy, histopathologic examination revealed papillary adenocarcinoma with a KRAS mutation. Residual CPAM prompted a lobectomy, emphasizing the importance of surgical intervention for cystic lesions.

Background

Food insecurity is associated with poor health outcomes; however, the connection with cancer care is not well understood. This study aimed to evaluate the impact of county-level food insecurity on the surgical management and survival of patients with esophageal cancer.

Methods

Patients with stage I to III esophageal cancer were identified from Surveillance Epidemiology and End Results data (2010-2016). County-level food insecurity rates were obtained from the Map the Meal Gap data (2010-2016), divided into quartiles: high, marginal, low, and very low. Multivariable and multinomial logistic regression analyses were used to examine the relationship between food insecurity and surgical intervention and the relationship between food insecurity and recommendation and receipt of surgery, respectively. Multivariable Cox proportional hazards modeling was used to evaluate 5-year cancer-specific survival.

Results

A total of 11,114 patients were identified, most of whom were male (78.8%) and non-Hispanic White (77.7%); 44.8% had stage III disease. The odds of undergoing surgical intervention were 27% lower among patients in high–food insecurity counties compared with very low–food insecurity counties (odds ratio, 0.73; 95% CI, 0.64-0.82). The odds of a patient’s being recommended surgery but not undergoing it was 38% higher among patients in high–food insecurity counties compared with very low–food insecurity counties (odds ratio, 1.38; 95% CI, 1.08-1.75). Patients in higher–food insecurity counties had worse survival when compared with patients in very low–food insecurity counties (high: hazard ratio, 1.26; 95% CI, 1.16-1.36).

Conclusions

Among patients with esophageal cancer, significant disparities in surgical resection and survival are associated with high county-level food insecurity. Interventions focused on these communities may help reduce inequities in esophageal cancer care.

The commissures are the supporting unit for the leaflets, and they play a vital role in the diastolic and systolic functioning of the mitral valve. This report describes the “ship technique” of commissural reconstruction in rheumatic mitral stenosis repairs. The technique overcomes gradients that are often encountered with limited commissurotomy and residual leaks observed with extended commissurotomy.

Aorticopulmonary paragangliomas are exceedingly rare tumors in pediatric populations. Complete surgical resection is the only curative treatment. However, resection is challenging due to the vascularity of paragangliomas and their close relationship with the great vessels. We present the resection of an aorticopulmonary paraganglioma that encased the main pulmonary artery bifurcation, compressed the left main coronary artery, and was densely adherent to the ascending aorta and right pulmonary artery via a median sternotomy with bypass. This case underscores the importance of complete resection for pediatric patients, despite the technical challenges.

A 39-year-old man with past medical history of type A aortic dissection presented to the emergency department with hematemesis, hypotension, and tachycardia. Imaging revealed an aortoesophageal fistula. The patient was taken emergently for thoracic endovascular aortic repair to cover the area of potential fistula. Due to the patient being a poor operative candidate, the decision was made to treat with endoluminal esophageal wound vacuum therapy. He underwent twice weekly endoscopies with sponge changes until discharge; he has done well since. Wound vacuum therapy in conjunction with thoracic endovascular aortic repair may represent a treatment option for patients with aortoesophageal fistula who are poor candidates for surgery.