An anastomotic leak is a potentially fatal complication after esophagectomy. This report describes the use of a dehydrated human amnion-chorion membrane (dHACM) placenta allograft patch for reinforcement of an esophageal anastomosis. The anastomotic technique was a modified Orringer procedure through a right thoracotomy (Ivor Lewis procedure). The anastomosis was reinforced with dHACM placenta allograft. Use of the allograft prevented anastomotic leaks and loss of gastrointestinal integrity. Early results are promising. (C) 2022 by The Society of Thoracic Surgeons

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Background. Reoperation after failed pectus repair, Open or Nuss, is complex. In the majority of patients, metal bars or plates are used. Recently, an absorbable bar (poly-L-lactide [PLA]) was introduced for rib fixation. This series is my experience of using this biomaterial for reoperative pectus surgery. Methods. We respectively reviewed the medical records of all patients who were referred to our institution for pectus abnormalities; 180 patients were evaluated, 62 patients (34%) underwent reoperation. Results. Sixty-two patients underwent reoperative Open repair. Median age was 38 years (range 18-, 72 years); 39 (63%) were men. Thirty-two patients had Open repair for recurrent pectus using posterior sternal support with PLA bars, and 30 patients with acquired restrictive thoracic dystrophy had expansion surgery with multiple PLA bars. Median hospital stay was 7 days (4-21 days). Postoperative complications occurred in 22 patients (35%); late complications in 10 patients (16%); all required reoperation for incisional or soft tissue issues. No patient required reoperation for a pectus or acquired restrictive thoracic dystrophy recurrence. Patient satisfaction was excellent in 85%, good in 8%, fair in 4%, and poor in 3%. Conclusions. Reoperative pectus surgery is complex and requires a detailed preoperative evaluation and individualized plan for correction. Use of PLA absorbable bars for sternal support and chest cavity expansion provides a safe alternative. Soft tissue complications are common and reversible; early results are promising in these challenging patients. (C) 2020 by The Society of Thoracic Surgeons.

Central MessageThe historical mechanism of compensatory sweating after thoracic sympathectomy for hyperhidrosis has been challenged and the successful treatment performed.See Article page 1481. The historical mechanism of compensatory sweating after thoracic sympathectomy for hyperhidrosis has been challenged and the successful treatment performed. See Article page 1481. Hyperhidrosis can be psychosocially unacceptable and when patients exhaust all conservative treatments they seek information about a minimally invasive sympathectomy (SX). Unfortunately, a significant number of individuals do not undergo a sympathectomy because of the fear of compensatory sweating (CS), which can be worse than the underlying disease itself. Modifications of the standard 3-level SX have been performed to reduce the incidence of CS, including single-level SX, lower-level SXs, ganglionectomy only, and reversible clamping, but no surgical variation has been 100% effective in preventing CS.1Miller D.L. Bryant A.S. Force S.D. Miller Jr., J.I. Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis.J Thorac Cardiovasc Surg. 2009; 138: 581-585Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 2Cerfolio R.J. De Campos J.R. Bryant A.S. Connery C.P. Miller D.L. DeCamp M.M. et al.The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis.Ann Thorac Surg. 2011; 91: 1642-1648Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar Treatment of CS has been limited to topical or oral agents, clamp removable or nerve interposition of the severed sympathetic chain with less-than-acceptable results of reversing CS. Yamamoto and colleagues,3Yamamoto H. Okada M. The management of compensatory sweating after thoracic sympathectomy.J Thorac Cardiovasc Surg. 2019; 158: 1481-1488Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar from among the largest hyperhidrosis centers in the world, report a small series of patients treated successfully with ganglionectomy based on skin blood flow to the CS area and not temperature change to eliminate CS. Historically, the mechanism of CS was believed to be a thermoregulatory response and untreatable. In the present study, the authors show that CS is not a physiological reaction. Eight patients with severe CS had intraoperative blood perfusion of the skin observed using laser speckle flowgraphy (LSFG), which determines the sympathetic nerves that are related to the area of skin with CS. Intraoperative monitoring using LSFG indicated the position of CS by electrical stimulation of the sympathetic ganglion and subsequent ganglionectomy was performed. In the skin area where CS was improved by ganglionectomy, a significant rise in the skin temperature was observed by postoperative thermography. Evidence that blood perfusion to the skin had increased. The authors attempted to observe the skin temperature intraoperatively; however, it was very difficult to find a significant change because of the slow speed of temperature change as well as other variables. Thus, they decided to measure the skin blood flow directly using LSFG because change in LSFG occurs within seconds after stimulating the ganglion. Interruption of the nerve circuits related to CS result in CS being ameliorated. The authors showed that CS did not increase on any other surfaces, although the area of anhidrosis was extended. Patients did not lose thermoregulatory function after the ganglionectomy because the emission of heat radiation increased from the anhidrosis area and the body temperature of the patients was constant. Therefore, CS is not a thermoregulatory response. The authors should be applauded for discovering the true mechanisms of CS, but more importantly successfully treating post-SX–debilitating CS. To confirm their hypothesis, other centers throughout the world will need to reproduce their intraoperative findings and postoperative success, which may be a daunting task that involves perfecting intraoperative LSFG. I look forward to that challenge and adventure! The management of compensatory sweating after thoracic sympathectomyThe Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 5PreviewThe main therapeutic method of treatment for local hyperhidrosis is endoscopic thoracic sympathectomy. Generally, resections of the sympathetic trunk or ganglia are performed between the second rib and sixth rib. However, this procedure can result in compensatory sweating, in which excess sweating occurs on the back, chest, and abdomen. Compensatory sweating has been regarded as a thermoregulatory response and thought to be untreatable. This study suggests that compensatory sweating is not a physiologic reaction and is indeed treatable. Full-Text PDF Open Archive

VATS lobectomies were associated with less 30-day mortality, shorter length of stay and fewer complications significantly compared to open lobectomies. Trends and Outcomes of Thoracoscopic Lobectomy or Segmentectomy: A National Surgical Quality Improvement Project AnalysisSeminars in Thoracic and Cardiovascular SurgeryVol. 30Issue 3PreviewVideo-assisted thoracoscopic surgery may be associated with less morbidity than open lobectomy or segmentectomy, but some studies have questioned the benefit of thoracoscopic surgery. This study aimed to determine trends and factors associated with patient's likelihood of undergoing thoracoscopic lobectomy or segmentectomy and to compare outcomes with each approach. This retrospective study included adult patients undergoing pulmonary lobectomy or segmentectomy from the American College of Surgeons National Surgical Quality Improvement Project from 2007 to 2015 (n = 14,717). Full-Text PDF

192 Background: Patient privacy is of the utmost importance for the emotional needs of a cancer patient and their family. As an effort to improve privacy, quality, and coordination of care within our Radiation Oncology department, in 2016 a patient pager system was devised to inform patients to prepare for daily treatment rather than verbally call the patient's name in waiting rooms. Methods: During June 2016, patients undergoing daily radiation therapy participated in a six-question survey addressing various aspects of the paging service, privacy prior to pager use, and demographics. Six radiation therapists also participated in a 7-question survey addressing privacy and workflow. Participants rated their experience on a scale of 1 to 5 (1 being poor, 5 being excellent). Surveys were collected and retrospectively reviewed. Results: 42 patients completed the survey. Patients rated "Very Good" to "Excellent" for the following categories: “Paging system more convenient than being called”(4.6), “Protection of privacy”(4.6), “Easiness”(4.7) and whether “Pager should be utilized for all appointments” (4.3). Patients rated “Patient privacy when name is called” as "Good" to "Very Good" (3.7). Seven patients also underwent therapy prior to pager implementation and rated the new system in comparison as "Very Good" to "Excellent" for “Privacy protection”(4.6), “Efficiency” (4.6), and “Satisfaction” (4.6). Only 24 filled out demographic information. Of the 24 patients, 54% of patients were female, 87% were above the age of 50, and all patients were receiving at least 10 treatments. Staff rated "Fair" to "Very Good" for “More preparation time” (2.8), “Patient use difficulty”(3.2), “Patient positive feedback”(2.3), “Receiving patients” (2.2) and “Workflow” (2). However, “Patient privacy” was rated as "Very Good" to "Excellent" (4.2). Conclusions: Overall, patients and staff highly rated the paging system for protecting privacy in the waiting room. Patients who experienced waiting room procedure prior to pager implementation display greater satisfaction with a paging system. However, it did not change overall workflow. Our study shows clinics should prioritize patient privacy in the waiting room to improve the emotional needs of the patient.

Lung cancer is the leading cause of cancer death in US. The American Cancer Society's estimates for lung cancer in the United States for 2016 are: approx 224,390 new cases of lung cancer and approx 158,080 deaths. Approximately 10-15% of lung cancers are classified as small cell (SCLC). These cancers portend a poor prognosis. Genomic sequencing of non-small cell lung cancer led to developing of new therapeutic modalities, i.e. targeted therapy with superior results to conventional cytotoxic chemotherapy. At this time, there is no approved targeted therapy for SCLC. In order to develop targeted therapies we need to identify and characterize molecular targets (alterations). This study aims to report our experience with genomic sequencing of SCLC. We performed a retrospective analysis of a dataset of 54 cases of SCLC, who underwent genomic sequencing. Patients were treated at 5 tertiary referral centers, between October 2012 and June 2016. The recorded data included: age at diagnosis, date of the genomic sequencing, genomic alteration (affected genes and the type of molecular alteration identified). For genomic profiling we used a platform commercially available (FoundationOne). We obtained 54 samples from 54 patients. Age range is 42 to 75 years, mean 60 and median 61 years old. All cases had a histologic diagnosis of SCLC. The genomic analysis found 88 affected genes with 230 alterations. The most common affected genes: Tp53 alteration, 45 cases (83%) and Rb1 33 cases (61%). There were an average of 4.3 mutations per patient; with a median of 4 mutations per patient, with a minimum of 0 and a maximum of 13. Sustained investigations and sequencing of larger numbers of SCLC are aiming to identify potential actionable mutations in these tumors. The ultimate goal is to determine new therapies and optimal treatment strategy based on the genomic profile.

Background. An anastomotic leak is the most devastating and potentially fatal complication after esophagectomy. Current detection methods can be inaccurate and place patients at risk of other complications. Analysis of pleural fluid for amylase may be more accurate and place patients at less of a risk for evaluating the integrity of an esophageal anastomosis. Methods. We retrospectively reviewed prospective data of 45 consecutive patients who underwent an Ivor Lewis esophagectomy over an 18-month period and evaluated their anastomotic integrity with serial pleural amylase levels (PAL). Results. There were 40 men (89%), and median age was 63 years (range, 35 to 79). Indication for esophagectomy was cancer in 38 patients (84%); 27 (71%) underwent neoadjuvant chemoradiation. A barium swallow was performed in the first 25 patients at median postoperative day (POD) 5 (range, 5 to 10); the swallow was negative in 23 patients (93%). Serial PALs were obtained starting on POD 3 and stopped 1 day after toleration of clear liquids. The PALs in the no-leak patients were highest on POD 3 (median 42 IU/L; range, 20 to 102 IU/L) and decreased (median 15 IU/L; range, 8 to 34 IU/L) to the lowest levels 1 day after clear liquid toleration (p = 0.04). Two patients had a leak and had peak PALs of 227 IU/L and 630 IU/L, respectively; both leaks occurred on POD 4, 1 day before their scheduled swallow test. The last 20 patients underwent serial PALs only, without a planned swallow test or computed tomography scan for anastomotic integrity evaluation. One of these patients had a leak on POD 5 with a low PAL of 55 IU/L the day before the spike of more than 4,000 IU/L. Two of the leaks were treated with esophageal stent placement and intravenous antibiotics, and the remaining patient's leak resolved with intravenous antibiotics, no oral intake, and observation only. None of the leak patients required transthoracic esophageal repair or drainage of an empyema. There was 1 postoperative death (2%) secondary to aspiration pneumonia on POD 10; no leak was ever identified, and the patient had been eating for 3 days before death. Complications occurred in 15 patients (33%), most commonly respiratory; no respiratory issues occurred in PAL-only evaluated patients. No late anastomotic leaks occurred in any patient while in the hospital or after discharge. Conclusions. Serial PALs for the detection of esophageal anastomotic leaks proved to be accurate, safe, and inexpensive. Elimination of barium swallows and computed tomography scans for evaluation of anastomotic integrity may decrease aspiration risks as well as associated pulmonary failure during the postoperative period. Serial PALs may be the preferred method of detecting an anastomotic leak after esophagectomy. A prospective randomized study is warranted. (C) 2018 by The Society of Thoracic Surgeons

To evaluate the safety and efficacy of hyperthermic pleural lavage (HTPL) with cisplatin in patients who have undergone cytoreductive surgery pleurectomy/decortication (PD) for isolated chemoresistant pleural metastases (PM). This may be an alternative treatment for patients with isolated pleural metastases with controlled primary disease. After Health Care System and Cancer Committee approval, 10 patients with unilateral chemo resistant pleural metastasis were registered prospectively. The patients primary sites of malignancy were under control for a median of 40 months (range, 28-76). Patients underwent a unilateral radical P/D and lymph node dissection, 60 minute pleural lavage (1,500 – 1,700 cc/min) with 225 mg/m2 of cisplatin at 42°C. Cisplatin levels were drawn at time zero, 1 hour, 4 hours, and 24 hours after completion of HTPL. Median age was 53 years (range, 38-64); 7 patients (70%) were women. Primary tumor: breast 5, colon 2, and thymic, renal cell and anal cancer 1 each. Surgical approach was a thoracotomy in 9 patients (90%). Morbidity included atrial fibrillation in 3 (30%), and acute respiratory distress syndrome in 1 (10%). Median hospital stay 7 days (range, 4-14). Serum cisplatin levels peaked at 4 hours after lavage; none to toxic range. Median dose of cisplatin was 386 mg (range, 299-450); no patient developed renal insufficiency. Median follow up was 10 months (range, 1-15). 8 patients had no signs of malignant disease at last follow up; 1 patient (anal cancer – 6 months) developed local recurrence and 1 patient (renal cell cancer – 9 months) developed contralateral pleural disease. All patients experienced improved quality of life, respiratory function, and reduced pleuritic pain. Surgical cytoreduction of chemoresistant PM followed by HTPL with cisplatin was well tolerated with no cisplatin-related toxicities. Early results are promising. This novel treatment for patients with isolated secondary PM represents the first series reported. Longer follow-up is warranted to determine a survival and quality of life advantage as well as defined inclusion and exclusion criteria.

Breast cancer is known to metastasize to the lung.. Most breast malignancies are clinically staged using radiographic modalities (e.g. PET scans). Importantly, many inflammatory disorders will present similar lymph node FDG-uptake on PET- as that of metastasized breast cancer. The latter confuses the treatment for individuals within whom both undiagnosed autoimmune disorders and breast cancer co-occur. We aim to examine the frequency of non-caseating granulomas diagnosed in PET avid mediastinal/hilar nodes in patients with known breast cancer. Between March 2013 and December 2015, 46 patients diagnosed with breast cancer were staged by PET-CT. Those with positive result in the mediastinum/hilum underwent linear endobronchial ultrasound (EBUS) for pathologic diagnosis and ensuing treatment. Of the 46 patients with avid mediastinal/hilar adenopathy, 31 (67%) had malignant cytology on EBUS; the remaining 15 had positive PET but negative cytology for malignancy. Twelve of the 15 patients with false positive PET had reactive lymph nodes, and 3 had non-caseating granulomas on cytology (table 1). Table 1Results from EBUS Procedure and Resulting Percentage Following Identification of Sarcoid-like SymptomsTotal Number of patients in study: n=46 with positive PETNumber of patientsPercentage of total (all PET positive patients)Percentage among negative patientsPositive EBUS3167.40%Negative EBUS1226.10%80%Negative/Non-caseating granulomas EBUS36.50%20% Open table in a new tab Twenty percent of the patients with negative cytology and positive PET had non-caseating granuloma, and 6.5 % of all patients with positive PET had non-caseating granulomas. This study represents the largest cohort of breast cancer patients, where the incidence of non-caseating granulomas is investigated in PET-positive mediastinal/hilar nodes. We conclude that PET may not be sufficient for staging the mediastinum in patients with breast cancer and, in selected patients, pathologic staging should be done. In addition, the finding of non-caseating granulomas in these patients may either indicate an incidental diagnosis of early stage sarcoidosis, or an inflammatory reaction to the current treatment (sarcomatoid reaction). We also suggest that these patients should be followed for any manifestations of sarcoidosis.

The supersymmetric QED Lagrangian with electrons and positrons having opposite charge, parity and statistics is investigated in details related to the ĈP̂ T̂ invariance and particle permutations. In the present theory the charge conjugation anticommutes with permutation of particles. The measurement of positron-positron scattering and the dipositronium ground state should prove or rule out the proposed symmetry; however the experimental evidences are not yet available.

The paper reports the commuting Right Weil spinors and the anticommuting Left Weil spinors obtained by the spontaneous symmetry breaking of the 4N dimensional massless Lagrangian to 4 dimensions. Once 4N−4 dimensions and related fields are integrated out, the statistics flip operator (scalar supercharge) emerges. The restrictions of the Coleman-Mandula theorem are automatically fulfilled. In the same time the scalar supercharge allows to bypass the Pauli principle for the Right Weil spinor.

e14569 Background: To evaluate the safety and efficacy of hyperthermic pleural lavage (HTPL) with cisplatin in patients who had undergone cytoreductive surgery pleurectomy/decortication (PD) for isolated chemoresistant pleural metastasis (PM). This may be an alternative treatment for patients with isolated pleural metastasis with controlled primary disease. Methods: After Health System and Cancer Committee approval, 10 patients with unilateral chemoresistant pleural metastasis were registered prospectively. The patients' primary sites of malignancy were under control for a median of 40 months (range, 32 - 61) prior to developing PM. Median time of systemic chemotherapy for PM was 29 months (range, 28 - 76). Patients underwent a unilateral radical P/D and lymph node dissection, 60 minutes pleural lavage (1,500 - 1,700 cc/min) with 225 mg/m2of cisplatin at 42°C. Cisplatin levels drawn at time zero, 1 hour, 4 hours, and 24 hours after completion of HTPL. Results: Median age was 53 years (range, 38 - 64); 7 patients (70%) were women. Primary tumor: breast 5, colon 2, and thymic, renal cell and anal cancer 1 each. Surgical approach was a thoracotomy in 9 patients (90%). Morbidity included atrial fibrillation in 3 (30%), prolonged air leak in 3 (30%), and acute respiratory distress syndrome in 1 (10%). Median hospital stay 7 days (range, 4 - 14). Serum cisplatin levels peaked at 4 hours after lavage; none in the toxic range. Median dose of cisplatin was 386 mg (range, 299 - 450); no patient developed renal insufficiency. Median follow-up was 10 months (range, 1 - 15). 8 patients had no signs of malignant disease at last follow-up; 1 patient (anal cancer – 6 months) developed local recurrence and 1 patient (renal cell cancer - 9 months) developed contralateral pleural disease. All patients experienced improved quality of life, respiratory function, and reduced pleuritic pain. Conclusions: Surgical cytoreduction of chemoresistant PM followed by HTPL with cisplatin was well tolerated with no cisplatin-related toxicities. Early results are promising. This novel treatment for patients with isolated secondary PM represents the first series reported. Longer follow-up is warranted to determine a survival and quality of life advantage as well as defined inclusion and exclusion criteria.

Background Lung cancer is the most common cause of cancer deaths in the United States. Overall survival is less than 20%, with the majority of patients presenting with advanced disease. The National Lung Screening Trial, performed mainly in academic medical centers, showed that cancer mortality can be reduced with computed tomography (CT) screening compared with chest radiography in high-risk patients. To determine whether this survival advantage can be duplicated in a community-based multidisciplinary thoracic oncology program, we initiated a CT scan screening program for lung cancer within an established health care system. Methods In 2008, we launched a lung cancer CT screening program within the WellStar Health System (WHS) consisting of five hospitals, three health parks, 140 outpatient medical offices, and 12 imaging centers that provide care in a five-county area of approximately 1.4 million people in Metro-Atlanta. Screening criteria incorporated were the International Early Lung Cancer Action Program (2008 to 2010) and National Comprehensive Cancer Network guidelines (2011 to 2013) for moderate- and high-risk patients. Results A total of 1,267 persons underwent CT lung cancer screening in WHS from 2008 through 2013; 53% were men, 87% were 50 years of age or older, and 83% were current or former smokers. Noncalcified indeterminate pulmonary nodules were found in 518 patients (41%). Thirty-six patients (2.8%) underwent a diagnostic procedure for positive findings on their CT scan; 30 proved to have cancer, 28 (2.2%) primary lung cancer and 2 metastatic cancer, and 6 had benign disease. Fourteen patients (50%) had their lung cancer discovered on their initial CT scan, 11 on subsequent scans associated with indeterminate pulmonary nodules growth and 3 patients who had a new indeterminate pulmonary nodules. Only 15 (54%) of these 28 patients would have qualified as a National Lung Screening Trial high-risk patient; 75% had stage I or II disease. Overall 5-year survival was 64% and 5-year cancer specific survival was 71% in the screened patients, whereas nonscreened lung cancer patients during that time in WHS had an overall survival of only 19% (p < 0.001). Conclusions A community-based multidisciplinary lung cancer screening program can improve survival of patients with lung cancer outside of a large multicenter study. This survival advantage was caused by a significant stage shift to earlier disease. Lung cancer CT screening may also benefit patients not meeting the National Lung Screening Trial criteria who are at moderate or high risk for lung cancer.

Background. The purpose of this study was to assess the efficacy of a digital versus traditional drainage system on hospitalization for patients undergoing video-assisted thoracoscopic surgery (VATS) anatomic lung resection.Methods. Consecutive patients who underwent VATS anatomic lung resection (July 2014 through January 2015) for lung cancer were analyzed. Patients were managed with overnight suction (-20 cm H2O) followed by gravity drainage (water seal or -8 cm H2O) in both the traditional and digital drainage systems, respectively; the digital system also allowed for continuous monitoring of air leaks. Chest tubes were removed when the air leak was absent for 12 hours and pleural drainage was less than 300 mL/24 h; patient outcomes selected by propensity matching were compared.Results. The VATS lung resections (lobectomy or segmentectomy) were performed in 108 patients during the 7-month study period. The pleural cavity was drained with the traditional system in 75 patients and with the digital system in 33 patients. By propensity score matching at a 2:1 ratio, 40 patients were placed in the traditional group and 20 patients, in the digital group for analysis. Demographics, percent predicted forced expiratory volume in 1 second, tumor size, stage, and type of resection were similar between the groups. The majority of patients (85%) underwent a lobectomy. There were no operative deaths. Overall complications were fewer in the digital system group (22%) compared with the traditional system group (35%; p = 0.01). Median air leak days (-1.1), chest tube days (-1.6), and total hospital stay (-1.5) were significantly reduced in the digital drainage system group.Conclusions. Patients undergoing VATS lung resections who were managed postoperatively with a digital drainage system experienced less morbidity and decreased hospitalization. A digital drainage system appears to be a safe alternative for management of the pleural cavity after VATS anatomic lung resection. (C) 2016 by The Society of Thoracic Surgeons

Langerhan’s cell sarcoma (LCS) is a rare neoplasm with a poor prognosis. To our knowledge, only sixty-six cases have been published. We discuss two patients who presented very differently with LCS, as well as a recently published review of all sixty-six cases. Our first case had a complicated history of metastatic, high-grade myxofibrosarcomas and presented with a single skin lesion of LCS which was treated with resection to a positive margin and adjuvant radiotherapy. The LCS recurred locoregionally and was again resected. The patient is alive two years after initial diagnosis. The second case presented with bone marrow and splenic involvement, leukocytosis, and thrombocytopenia. This patient had an excellent response to etoposide, prednisone, oncovorin, cyclophosphamide, and adriamycin, with normalization of the complete blood count, negative bone marrow biopsy at follow up, and splenectomy without viable neoplasm. This patient is alive without signs of disease at 16 months after initial diagnosis.