The use of a tailored surgical technique for minimally invasive esophagectomy

ObjectiveUncertainty exists among surgeons as to whether minimally invasive esophagectomy (MIE) is a comparable operation to open esophagectomy (OE). The surgical technique and oncologic dissection should not be degraded when using a minimally invasive approach.MethodsWe reviewed a single hospital’s experience with both OE and MIE. From 2000 to 2010, 257 patients underwent esophagectomy by 1 of 3 surgical techniques: transhiatal, Ivor Lewis, or 3-hole.ResultsOf the 257 patients (median age, 67 years; range, 58–74), 92 underwent MIE. Both groups were comparable in terms of gender, age, comorbidities, surgical technique, and induction chemotherapy and radiotherapy. The overall median follow-up was 29.5 months (range, 9.9–61.5). The MIE group had a significantly shorter operative time (MIE vs OE, 330 vs 365 minutes, P = .04), length of stay (MIE vs OE, 9 vs 12 days, P < .01), intensive care unit admission rate (MIE vs OE, 55% vs 81%, P < .01), intensive care unit length of stay (MIE vs OE, 1 vs 2 days, P < .01), and estimated blood loss (MIE vs OE, 100 vs 400 mL, P < .01). More lymph nodes were harvested in the MIE group than in the OE group (17 vs 11 nodes, P < .01). There were insignificant differences in 30-day mortality (MIE vs OE, 2.2% vs 3.0%; P = .93) and overall survival (P = .19), as well as in the rates of all complications, except pneumonia (MIE vs OE, 2% vs 13%; P = .01).ConclusionsA thoracic surgeon can safely tailor the MIE to a patient’s anatomy and oncologic demands while maintaining equivalent survival

Platelet activation in the postoperative period after lung transplantation

Objective During lung transplantation, cells in the pulmonary parenchyma are subjected to ischemia, hypothermic storage, and reperfusion injury. Platelets, whose granular contents include adhesion receptors, chemokines, and coactivating substances that activate inflammatory and coagulant cascades, likely play a critical role in the lung allograft response to ischemia and reperfusion. The platelet response to the pulmonary allograft, however, has never been studied. Here we report significant platelet activation immediately after lung transplantation. Methods We performed a prospective cohort study comparing markers of platelet activation in patients undergoing lung transplantation and patients undergoing nontransplant thoracotomy. Plasma levels of soluble P-selectin, soluble CD40 ligand, and platelet–leukocyte conjugates were measured before surgery, after skin closure, and at 6 postoperative hours. Results Both soluble P-selectin and soluble CD40 ligand levels increased significantly after lung transplantation but not after thoracotomy. Additionally, platelet–monocyte conjugate fluorescence was significantly higher after lung transplantation than after thoracotomy alone. Conclusion These findings suggest that platelet activation is significantly increased after lung transplantation beyond that expected from the postoperative state. The increase in circulating platelet–monocyte conjugates suggests an important interaction between platelets and inflammatory cells. Further research should examine whether platelet activation affects early graft function after lung transplantation

Chest Drainage Therapy: What Comes out of Pandora&rsquo;s Box Can Affect Patient Outcomes

Background: Over the last 100 years, the original three-bottle chest drainage system has been variously engineered into compact disposables and electronic units. Clinicians are now surrounded by a plethora of different types of systems, but little is known about the way that they work and perform. Thus, we sought to test the performance of the most commonly used chest drainage units under conditions that are relevant to clinical practice. Methods: A pleural space environment simulator was built. Thirty-two units were tested under four clinical scenarios: air leak interpretation during quiet breathing and after obstructed inspiration (&minus;5 to &minus;150 cmH2O), a buildup of negative pressure (&minus;100 cmH2O), a bronchopleural fistula (10 L/min) and the need for effective external suction in the presence of air leakage. Twenty-five units were &ldquo;traditional&rdquo; thoracic drainages, five were &ldquo;digital&rdquo; low-flow/low-vacuum pumps and two were hybrids (a combination of the two). According to the design of the seal and of the suction control, the units were classified as wet-wet, wet-dry and dry-dry. Results: All wet units showed reverse air flow, with the potential to mimic an air leak when there was none. Ten wet units showed no automatic negative pressure relief features, while five dry-dry did but were slow to react. Ten wet and five dry-dry units showed no capability to handle a 10 L/min leak, as they were restrictive to flow (peak pressure up to 55 cmH2O). Only seven dry-suction units were able to maintain the set suction at high airflow rates (&gt;20 L/min). Conclusions: Different chest drainage unit designs lead to different performances, some of which may negatively impact patient outcomes. This sounds the call to tailor our clinical practice for the individual patient. A paradigm shift to better understand all components of pleural physiology post-surgical intervention on this relatively neglected topic is needed to improve our daily practice

Six-Minute-Walk Distance Predicts Waiting List Survival in Idiopathic Pulmonary Fibrosis

Rationale: Functional studies may be useful to predict survival in idiopathic pulmonary fibrosis (IPF). Various cutoffs of 6-min-walk distance (6MWD) have been suggested to identify patients at a high risk of death