Extended cervical approach for retrosternal multinodular goiter

Objective

Partial or total sternotomy is required for 10% of retrosternal goiter. This study reviewed our experience with an extended cervicotomic approach as an alternative surgical solution for retrosternal goiter.

Methods

A retrospective study was performed on patients who underwent partial or total thyroidectomy for retrosternal goiter between 2014 and 2019 at a tertiary medical centre. Data on clinical, radiologic, and pathologic factors were analysed. Peri- and postoperative outcomes were compared between extended and standard cervical approaches to predict the need for an extended cervical approach.

Results

The cohort included 265 patients, of whom 245 (92.4%) were treated by standard thyroidectomy. In 17 (6.4%), the standard approach proved insufficient, and the horizontal incision was extended to a T-shape to improve access. The remaining 3 patients required a sternotomy. Use of the extended cervical approach was significantly associated with clinical features such as male gender, diabetes, high body mass index and postoperative hypocalcaemia.

Conclusions

The extended cervicotomic approach is an alternative surgical solution for retrosternal goiter, with no increased risk of significant post-operative complications.

[SURGICAL TREATMENT VERSUS ENDOSCOPIC TREATMENT FOR ACHALASIA IN THE MODERN ERA]

INTRODUCTION

Achalasia is a disorder of esophageal motility characterized by absent relaxation of the lower esophageal sphincter and abnormal peristalsis of the esophagus during swallowing. The etiology is divided into primary idiopathic achalasia and secondary achalasia and classified into 3 subtypes based on manometric evaluation, according to the Chicago 4.0 classification. The goal of the therapy is symptomatic improvement and prevention of late complications. While there are several endoscopic therapies, the gold standard therapy is laparoscopic Heller myotomy. Since its debut in 2008, per-oral-endoscopic-myotomy (POEM) became an accepted treatment for achalasia with non-inferior short term outcomes compared to Heller myotomy. In the following review, we will explore the indications, guidelines, and controversies in the modern treatment of achalsia, focusing on the Heller myotomy versus POEM.

Post-radiotherapy osteomyelitis of the cervical spine in head and neck cancer patients

Objective

To evaluate patient characteristics, risk factors, disease course, and management of cervical vertebral osteomyelitis in patients who had radiation for head and neck cancers.

Methods

A retrospective cohort study (case series) of patients diagnosed with post-radiation osteomyelitis of the cervical spine between 2012 and 2021. Data were collected from the patient's medical files.

Results

Seven patients (71% male) with post-radiation cervical osteomyelitis were reviewed. The median patient age was 64 years. The mean interval between diagnosis of osteomyelitis and the first and last radiotherapy course was 8.3 and 4.0 years, respectively. A medical or surgical event preceded the diagnosis in four patients (57%) by a mean of 46.25 days. Common imaging findings were free air within the cervical structures and fluid collection. Four patients recovered from osteomyelitis during the follow-up within an average of 65 days.

Conclusion

Post-radiation osteomyelitis is characterized by a subtle presentation, challenging diagnosis, prolonged treatment, and poor outcome. Clinicians should maintain a high index of suspicion for the long-term after radiotherapy. Multidisciplinary evaluation and management are warranted.

Advances in knowledge

The study describes post-radiotherapy osteomyelitis of the cervical spine, a rare and devastating complication. Literature data regarding this complication are sparse.

The Whiteboard Time Out: A Novel Tool to Improve Resident Learning in the Operating Room

OBJECTIVE

"Flipping the classroom" is a strategy that has been implemented in various educational environments to create a student-centered learning environment. Within this model of teaching, "first exposure" occurs prior to the classroom in a lower form of cognitive demand, allowing students to employ higher forms of cognition within the classroom. Surgical education has evolved over recent years to incorporate different modalities of learning; however, optimal educational approaches within the operating room (OR) have not been clearly defined. The Whiteboard Time Out (WBTO) utilizes the idea of "flipping the classroom" to make learning within the OR more resident centered. Residents complete most of the preoperative work prior to the case with a focus on the indications, steps of the procedure, and potential complications associated with the procedure. Residents then utilize a whiteboard located in the OR to outline, diagram, and discuss this information with the attending. Aims of the study are to enhance higher level intraoperative resident learning and attending teaching and improve resident knowledge and the ability to communicate surgical steps.

DESIGN

Faculty and residents completed a preimplementation questionnaire aligned to the Student Evaluation of Educational Quality (SEEQ) in July 2021. Participants were assigned 3 digit codes to ensure anonymity. The questionnaire was composed of 6 questions with a 5-point Likert scale. Whiteboards were mounted in every operating room, 19 total, in both the general OR and an ambulatory surgical center. The residents were expected to go to the OR, prior to scrubbing the case, and use the whiteboard to outline the indications, key steps and potential complications. After the resident completed the white board, the resident and attending reviewed the white board together prior to the start of the case. After the procedure, residents uploaded a picture of the whiteboard with a self-evaluation and faculty provided resident feedback via an online Wufoo Survey link. The start of the utilization of the whiteboards occurred after the initial survey in July 2021. The SEEQ questionnaire was again administered in October 2021, 3 months post-WBTO implementation, to assess resident and attending satisfaction. SEEQ questionnaire results were compared using a t-test.

PARTICIPANTS

Participants included surgical residents and attendings at Maimonides Medical Center (MMC). MMC is a 700-bed university-affiliated, academic, tertiary medical center in Brooklyn, New York. The General Surgery Residency is approved for up to 5 graduates annually.

RESULTS

A total of 17 attendings and 17 residents filled out the questionnaire. The average number of whiteboards completed was highest amongst the PGY1 class with an average of 18 whiteboards per resident. However, the average number of whiteboards completed declined amongst more senior residents. There was a statistically significant increase in overall SEEQ survey score amongst residents and attendings after implementation of the WBTO suggesting that whiteboards were useful (p < 0.03 and p < 0.02, respectively). Residents found that the whiteboard was an effective means of teaching surgical education compared to the current curriculum (p < 0.04).

CONCLUSIONS

The whiteboard timeout is a tool created to enhance resident education in the OR. This idea is centered on a "flipped classroom," an educational strategy to increase student engagement. Our data demonstrates that the whiteboard timeout is an effective method of intraoperative teaching.

A Novel Urine Test Biosensor Platform for Early Lung Cancer Detection

Lung cancer is the leading cause of cancer-related mortality worldwide. Early detection is essential to achieving a better outcome and prognosis. Volatile organic compounds (VOCs) reflect alterations in the pathophysiology and body metabolism processes, as shown in various types of cancers. The biosensor platform (BSP) urine test uses animals' unique, proficient, and accurate ability to scent lung cancer VOCs. The BSP is a testing platform for the binary (negative/positive) recognition of the signature VOCs of lung cancer by trained and qualified Long-Evans rats as biosensors (BSs). The results of the current double-blind study show high accuracy in lung cancer VOC recognition, with 93% sensitivity and 91% specificity. The BSP test is safe, rapid, objective and can be performed repetitively, enabling periodic cancer monitoring as well as an aid to existing diagnostic methods. The future implementation of such urine tests as routine screening and monitoring tools has the potential to significantly increase detection rate as well as curability rates with lower healthcare expenditure. This paper offers a first instructive clinical platform utilizing VOC's in urine for detection of lung cancer using the innovative BSP to deal with the pressing need for an early lung cancer detection test tool.

Thyroid-split tracheostomy: short- and long-term outcomes

Objective

Compare long-term outcomes of thyroid-split and standard thyroid-retraction tracheostomy in a large cohort.

Methods

The healthcare database of a university-affiliated hospital was searched for past patients over 18 years of age from all of the hospital's wards on whom an ear, nose, and throat specialist performed a tracheostomy in the operating room between 2010 and 2020. Clinical data were extracted from the hospital and outpatient medical records. Life-threatening and non-life-threatening intra-operative and early and late post-operative adverse events in patients who underwent split-thyroid tracheostomy were compared with those who underwent standard tracheostomy.

Results

There was no significant difference in intra-operative and early post-operative complications, hospitalisation length, or early reoperation and death rates between the 140 (28%) thyroid-split tracheostomy patients and the 354 (72%) standard tracheostomy patients, although the thyroid-split group had more non-decannulated patients and a longer operative time.

Conclusions

Thyroid-split tracheostomy is safe and feasible. Compared to the standard procedure, it provides better exposure and a similar rate of complications, although its de-cannulation success rate is lower.

Predicting Factors for a Favorable Pathologic Response to Neoadjuvant Therapy in Esophageal Cancer

BACKGROUND

Favorable pathologic response(FPR) is a significant predictor for improved survival following Neoadjuvant therapy(NAT) in esophageal and gastroesophageal cancer(GEJ). Preoperative prediction of FPR could modify treatment plans. No reliable method for predicting FPR exists. We sought to identify preoperative predicting factors for FPR.

MATERIALS AND METHODS

Retrospective analysis of patients with esophageal and GEJ cancer who underwent esophagectomy following (NAT). Univariate and multivariate analysis was used to identify preoperative predicting factors for FPR. A comparison of Tumor Regression Grade(TRG) was used to assess treatment response on overall survival(OS).

RESULTS

Out of 121 patients, 82(67.8%) had neoadjuvant chemoradiation. FPR was observed in 60(49.6%). Female sex, Radiation therapy(RT), squamous cell carcinoma(SCC), lack of signet ring feature, and FDG avidity posttreatment were associated with FPR on univariate analysis. RT and SCC were associated with FPR (OR=3.9 and 4.0, respectively) on multivariate analysis. OS was lower among patients who did not achieve FPR to NAT(P=0.027).

CONCLUSIONS

FPR is a predictor of improved OS. SCC and radiation therapy-based protocol were identified as major prediction factors of FPR in patients with esophageal and GEJ cancers.

Perspective and practice patterns of mediastinal staging among thoracic surgeons

Background

Accurate mediastinal staging of lung cancer patients is critical for determining appropriate treatment. Mediastinoscopy and endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration are the most commonly utilized techniques. Limited data exist on training and practice trends among thoracic surgeons. We aimed to determine training and practice patterns and find whether there is a paradigm shift in mediastinal staging after the introduction of EBUS into practice among thoracic surgeons in the United States.

Methods

28-question survey was constructed querying demographic, training, and practice patterns with mediastinoscopy and EBUS and was sent to practicing thoracic surgeons in the United States. Descriptive statistics were used to summarize quantitative data.

Results

Ninety-eight responded with a 93% completion rate. Eighty-seven percent of respondents received training in EBUS and 70% perform EBUS routinely. All respondents believe EBUS should be incorporated into thoracic surgery training curriculums. Majority of those who prefer EBUS feel EBUS is safer than mediastinoscopy, allows access to lymph nodes stations or lesions inaccessible by mediastinoscopy and prefer EBUS to avoid re-do mediastinoscopy and in irradiated mediastinum. Majority of those who prefer mediastinoscopy reported they perform more accurate staging compared to EBUS, that mediastinoscopy is more accurate in diagnosing lymphoma or sarcoidosis and that frozen section can be done at the same interval as resection. Among surgeons who prefer EBUS, 94% biopsy 3 or more lymph node stations, 86% routinely biopsy hilar (N1) nodes while 8% never biopsy N1 nodes. Of surgeons who prefer mediastinoscopy. Ninety-seven percent biopsy 3 or more lymph node stations, only 27% routinely biopsy N1 nodes and 70% never biopsy N1 nodes.

Conclusions

EBUS is used frequently by thoracic surgeons in their practice for mediastinal staging. Methods of obtaining proficiency in EBUS widely varied among surgeons. In addition to mediastinoscopy, dedicated EBUS training should be incorporated into thoracic surgery training curriculums.

From Chest Wall Resection to Medical Management: The Continued Saga of Parapneumonic Effusion Management and Future Directions

Pleural space infections have been described since the time of Hippocrates and to this day remains a significant pathology. Every year in the USA approximately there are one million hospital admissions for pneumonia with 20%-40% associated with some form of pleural space infections leading to pleural effusions with increased morbidity and mortality. Often, management of these effusions mandate combination of medical treatment and surgical drainage with debridement and decortication. There has been a lot of ongoing research regarding the safety and efficacy of intrapleural fibrinolytics in the management of complicated pleural effusions and empyema. Till this day, areas of debate and controversies exist among clinicians treating pleural space infection. Empyema is historically considered a surgical disease. There have been societies and guidelines for the management of infected parapneumonic effusions with antibiotics and chest tube drainage as an initial empiric treatment modality. With the advances in the use of Intrapleural fibrinolytics and minimally invasive procedures such as video-assisted thoracoscopic surgery (VATS), empyema a surgical disease is now more favoring medical management. Surgical option, such as open thoracotomy, is reserved for patients who failed conservative management and chronic empyema. The aim of this comprehensive review is to shed light on the evolution of various management strategies from the era of Hippocrates to current day practice and how there continues to be a paradigm shift in treating empyema as a surgical condition to a medical disease.

Thoracic surgery in Israel

During the past 74 years since its establishment, Israel has evolved into a modernized country with well-established and effective public health care system. Thoracic surgeons in Israel play a central role in the diagnosis and treatment of patients with diseases of the chest wall, diaphragm, mediastinum, airways, Lung, and esophagus as well are taking part in designated trauma teams. Between 2,500–3,000 cases are being performed in 16 designated thoracic surgical units and departments across the country annually, the majority of them being performed in a minimally invasive fashion. Lung cancer is the leading cause of cancer related mortality in Israel and the second most common cancer in Israel. All types of thoracic oncologic cases are being presented routinely during designated multi-disciplinary conferences and treatment plans are designed according to the most up to date international guidelines. Each surgeon undergoes at least 6 years of formal training, followed by certifying exams. Advanced training is usually obtained overseas in centers of excellence. Israeli thoracic surgeons are part of an international societies and are actively involved in academic research. Despite the advancement of the Israeli health care system, thoracic surgeons in Israel are still facing few challenges that are limiting the early diagnosis of thoracic surgical malignancies such as lack of established national lung cancer screening program in Israel although a pilot program is being tested during these days. Tasked with taking care of diseases of the chest, and in order to remain at the forefront of diagnosis and treatment similar to our colleagues across the globe, Thoracic surgeons in Israel are continuously seeking to learn and evolve in order to improve and provide better care to our patients.

The impact of cervical anastomotic leak after esophagectomy on long-term survival of patients with esophageal cancer

BACKGROUND

Anastomotic leak is a major complication after esophagectomy. There is a paucity of data on long-term oncological outcomes of cervical anastomotic leak after esophagectomy for cancer. We evaluated the impact of such a leak on postoperative outcomes as well as on long-term oncological outcomes.

METHODS

A retrospective analysis of a prospectively maintained database of patients with esophageal cancer who underwent esophagectomy with a cervical esophagogastric anastomosis between 2010 and 2017. Patients were divided into 3 groups: patients with no anastomotic leak; patients with nonsevere (type 1 & 2) leak, and patients with severe (type 3) leak. A comparison of postoperative and long-term oncological outcomes was made between the groups.

RESULTS

Two hundred and eight patients were included in this study. Thirty-two (15%) patients had cervical anastomotic leak, of which 20 (63%) had type 1 and 2 (nonsevere) leak, and 12 (37%) had type 3 (severe) leak. Overall, 30-day mortality rate was 7%. Mortality rate was 4% in patients without leak, 15% in patients with nonsevere leak, and 25% in patients with severe anastomotic leak (P = .007). Overall median survival was 42 months. Patients with severe leak had poorer overall survival compared to patients with nonsevere and no anastomotic leak (6, 38, and 39 months, respectively, P = .011). There was no difference in disease-free survival of patients with or without anastomotic leak.

CONCLUSION

Leakage from cervical anastomosis after esophagectomy had no impact on disease-free survival of patients with esophageal cancer. Severe anastomotic leak was associated with lower overall survival, probably due to a high rate of postoperative mortality.

A multicenter single-arm trial of sintilimab in combination with chemotherapy for neoadjuvant treatment of resectable esophageal cancer (SIN-ICE study)

Background

Preoperative chemotherapy or chemoradiotherapy is the standard treatment for resectable esophageal cancer (EC); however, it is associated with increased postoperative complications and mortality. Recently, Immune Checkpoint inhibitors have been incorporated in the treatment of advanced EC. Its role in the preoperative setting has not been established yet. In this multicenter, single-arm study, we evaluated the efficacy and safety of neoadjuvant therapy with sintilimab in combination with chemotherapy in treating EC.

Methods

Patients received neoadjuvant therapy with 3 cycles of sintilimab 200 mg Q3W in combination with platinum-based chemotherapy. Surgery was performed within 4–6 weeks after neoadjuvant therapy. The primary endpoints of the trial were pathological complete response (pCR) and safety.

Results

A total of 23 patients (21 men and 2 women) were enrolled. Surgery was completed in 17 participants, with 16 achieving R0 resection and 1 had R1 resection, 5 participants refused surgery. One patient progressed prior to surgery. Twenty one patients (91%) had significant improvement in their dysphagia following treatment as assessed by Stooler’s criteria. The majority of patients who underwent resection have a good pathological response and downstaging rate was 76.5% (13/17). A pCR was achieved in 6 cases (6/17, 35.3%) and major pathological response (MPR) in 9 cases (9/17, 52.9%). The main preoperative adverse events (AEs) were vomiting (13/23, 56.5%), leukopenia (12/23, 52.2%), neutropenia (9/23, 39.1%), and malaise (8/23, 34.8%). Immune-related AEs were mild and included hypothyroidism (2/23, 8.7%) and rash (4/23, 17.4%). The incidence of ≥ grade 3 treatment related AEs was 30.4% (7/23). There were no ≥ grade 4 AEs.

Conclusions

Sintilimab in combination with chemotherapy in the neoadjuvant treatment of EC is safe and lead to a high pCR. Therefore, further testing is warranted.

Assessing the development status of intraoperative fluorescence imaging for perfusion assessments, using the IDEAL framework

Objectives

Intraoperative fluorescence imaging is currently used in a variety of surgical fields for four main purposes: assessing tissue perfusion; identifying/localizing cancer; mapping lymphatic systems; and visualizing anatomy. To establish evidence-based guidance for research and practice, understanding the state of research on fluorescence imaging in different surgical fields is needed. We evaluated the evidence on fluorescence imaging for perfusion assessments using the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework, which was designed for describing the stages of innovation in surgery and other interventional procedures.

Design

Narrative literature review with analysis of IDEAL stage of each field of study.

Setting

All publications on intraoperative fluorescence imaging for perfusion assessments reported in PubMed through 2019 were identified for six surgical procedures: coronary artery bypass grafting (CABG), upper gastrointestinal (GI) surgery, colorectal surgery, solid organ transplantation, reconstructive surgery, and cerebral aneurysm surgery.

Main outcome measures

The IDEAL stage of research evidence was determined for each specialty field using a previously described approach.

Results

196 articles (15 003 cases) were selected for analysis. Current status of research evidence was determined to be IDEAL Stage 2a for upper GI and transplantation surgery, IDEAL 2b for CABG, colorectal and cerebral aneurysm surgery, and IDEAL Stage 3 for reconstructive surgery. Using the technique resulted in a high (up to 50%) rate of revisions among surgical procedures, but its efficacy improving postoperative outcomes has not yet been demonstrated by randomized controlled trials in any discipline. Only one possible adverse reaction to intravenous indocyanine green was reported.

Conclusions

Using fluorescence imaging intraoperatively to assess perfusion is feasible and appears useful for surgical decision making across a range of disciplines. Identifying the IDEAL stage of current research knowledge aids in planning further studies to establish the potential for patient benefit.

Outcomes of Barotrauma in Critically Ill COVID-19 Patients With Severe Pneumonia

Background:

Pneumomediastinum and pneumothorax are complications which may be associated with barotrauma in mechanically ventilated patients. The current literature demonstrates unclear outcomes regarding barotrauma in critically ill patients with severe COVID-19. The purpose of this study was to examine the incidence of barotrauma in patients with severe COVID-19 pneumonia and its influence on survival.

Study Design and Methods:

A retrospective cohort study was performed from March 18, 2020 to May 5, 2020, with follow-up through June 18, 2020, encompassing critically ill intubated patients admitted for COVID-19 pneumonia at an academic tertiary care hospital in Brooklyn, New York. Critically ill patients with pneumomediastinum, pneumothorax, or both (n = 75) were compared to those without evidence of barotrauma (n = 206). Clinical characteristics and short-term patient outcomes were analyzed.

Results:

Barotrauma occurred in 75/281 (26.7%) of included patients. On multivariable analysis, factors associated with increased 30-day mortality were elevated age (HR 1.015 [95% CI 1.004-1.027], P = 0.006), barotrauma (1.417 [1.040-1.931], P = 0.027), and renal dysfunction (1.602 [1.055-2.432], P = 0.027). Protective factors were administration of remdesivir (0.479 [0.321-0.714], P < 0.001) and receipt of steroids (0.488 [0.370-0.643], P < 0.001).

Conclusion:

Barotrauma occurred at high rates in intubated critically ill patients with COVID-19 pneumonia and was found to be an independent risk factor for 30-day mortality.

History of esophagectomy for cancer of the esophagus and the gastroesophageal junction

The introduction of anesthesia in 1846 created unseen opportunities for surgeons. By the end of the 19th century limited esophageal resection outside the chest had already been performed and the race for successful intrathoracic esophagectomy was on. The credit for the first successful esophagectomy for an intrathoracic cancer goes to Franz Torek of New York in 1913. But it was the introduction of double lumen intubation that really boosted the number of successful esophagectomies all over the world. In the second half of the 20th century progress in surgical techniques and perioperative management resulted in a substantial reduction of postoperative mortality. Introduction of multimodality therapies has further improved long term survival. The turn of the millennium saw the development of minimally invasive esophagectomy (MIE) improving postoperative quality of life. Undoubtly new technologies and newer drugs (e.g., immunotherapy) will further allow for refinements and more personalized targeted therapies. In this manuscript, the authors provide a deep dive into the history and development of esophageal surgery, with emphasis on the innovative pioneers that brought the field of esophageal surgery to the front line of surgery.

A narrative review of esophageal tissue engineering and replacement: where are we?

Long-gap esophageal defects, whether congenital or acquired, are very difficult to manage. Any significant surgical peri-esophageal dissection that is performed to allow for potential stretching of two ends of a defect interrupts the esophageal blood supply and leads to complications such as leak and stricture, even in the youngest, healthiest patients. The term “congenital” applied to these defects refers mainly to long-gap esophageal atresia (LGA). Causes of acquired long-segment esophageal disruption include recurrent leaks and fistulae after primary repair, refractory GERD, caustic ingestions, cancer, and strictures. 5,000–10,000 patients per year in the US require esophageal replacement. Gastric, colonic, and jejunal pull-up surgeries are fraught with high rates of both short and long term complications thus creating a space for a better option. Since the 1970’s many groups around the world have been unsuccessfully attempting esophageal replacement with tissue-engineered grafts in various animal models. But, recent advances in these models are now combining novel technologic advances in materials bioscience, stem-cell therapies, and transplantation and are showing increasing promise to human translational application. Transplantation has been heretofore unsuccessful, but given modern improvements in transplant microsurgery and immunosuppressive medications, pioneering trials in animal models are being undertaken now. These rapidly evolving medical innovations will be reviewed here.

A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery

The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.

Fluorescence-guided surgery of the esophagus

The use of indocyanine green (ICG) fluorescence near-infrared (NIR) imaging during gastrointestinal surgery has surged in recent years. Its use in esophageal surgery is actively being studied both in the clinical setting and in the lab. NIR imaging has several important applications in esophageal surgery including assessing perfusion of the gastrointestinal-esophageal anastomosis, lymphatic drainage and tracheal blood flow after mediastinal dissection. This is a review of the modern literature summarizing the current knowledge on fluorescence-guided surgery of the esophagus.

Rapid Adoption of an Interdisciplinary Care Team Model for Surgical Residents Managing Coronavirus Disease-19

Introduction: Patients infected with SARS-Cov-2, the causative virus behind the coronavirus disease-19 (COVID-19) pandemic, have been increasing rapidly in New York City. New York City has the highest incidence in the United States and fully 45% of all deaths from COVID-19. Our medical center is located within a high-density region of cases in south Brooklyn and, in fact, three of our neighborhood zip codes are in the top seven in New York in incidence. As a result, our center has experienced a dramatic increase in hospitalizations, particularly respiratory distress secondary to COVID-19, which rapidly exceeded the capacity of our internal medicine service. This necessitated the formation of new COVID-19 units throughout the hospital, replacing all former service lines. These units employed management teams composed of residents from many medical and surgical disciplines, including general surgery residents. Methods: Our general surgery residency program established a surgical COVID-19 (SCOVID) management team. Initially, 4 surgical residents (2 senior and 2 junior), 1 attending surgeon, and 1 attending internal medicine physician were allocated to the initial SCOVID team. On day 3 of implementation, to achieve more rapid competence in the complex management of these patients, a senior medicine resident with direct experience in the care of COVID-19 patients was added in an advisory capacity. Results: The addition of an experienced senior medical resident and attending allowed for the quick adoption of uniform management protocols by surgical residents and attendings. Discussion: We describe a protocol for the establishment of COVID-19 management teams staffed with general surgical residents, as well as a strategy for the achievement of rapid increases in competency. The addition of a senior internal medicine resident and attending to our SCOVID team allowed for rapid achievement of competency in the care of COVID-19 patients in our large institution at the epicenter of the COVID-19 pandemic.

The prevalence of asymptomatic COVID-19 infection in cancer patients. A cross-sectional study at a tertiary cancer center in New York City

Objective

Several factors raise concern for increased risk of COVID-19 in cancer patients. While there is strong support for testing symptomatic patients. The benefit of routine testing of asymptomatic patients remains contentious. We aim to evaluate the prevalence of asymptomatic COVID-19 infection in cancer patients.

Methods

Between June 1 and September 3, 2020, we obtained nasopharyngeal swab from asymptomatic cancer patients who were visiting a single tertiary-care cancer center, and tested the specimen for the presence or absence of SARS-CoV-2 RNA. We performed a descriptive statistic of data

Results

We tested a total of 80 patients, of which 3 (3.75%) were found positive for COVID-19. A significant proportion of the tested patients were on active immunosuppressive or immunomodulatory treatment, cytotoxic chemotherapy (n = 34), and immunotherapy (n = 16). However, all three COVID-19 positive patients were only actively on hormonal therapy. All three patients observed a minimum of 2 weeks home quarantine. None of the patients developed symptoms upon follow up and no changes were required to their treatment plan.

Conclusions

Despite published evidence that cancer patients may be at increased risk of severe COVID -19 infection, our data suggest that some infected cancer patients are asymptomatic. The overall prevalence of asymptomatic COVID-19 infection in this population of cancer patients was similar to that in the general population. Therefore, since asymptomatic infections are not uncommon in patients with cancer, we recommend universal COVID-19 testing to help guide treatment decisions and prevent the spread of the disease.

Gastrointestinal perforation in a critically ill patient with COVID-19 pneumonia

Gastrointestinal complications in critically ill patients during the COVID-19 pandemic pose a diagnostic and treatment dilemma. We present a case of a 74-year-old male who was brought to our emergency department with worsening shortness of breath, fever, and dry cough and was found to have COVID-19 pneumonia. Early in his hospital course, he was admitted to the intensive care unit, and was found to have significant abdominal distension with large amounts of simple fluid on bedside ultrasound. Bedside paracentesis returned succus and enteric feeds, and a methylene blue test confirmed a likely gastrointestinal perforation. The patients’ family refused surgical intervention and the patient underwent bedside drainage. This case represents several critical dilemmas clinicians faced during the recent surge of the COVID-19 pandemic.

Safe extubation during the COVID-19 pandemic

Extubation of patients with Coronavirus Disease 2019 (COVID-19) is a high risk procedure for both patients and staff. Shortages in personal protective equipment (PPE) and the high volume of contact staff have with COVID-19 patients has generated an interest in ways to reduce exposure that might be feasible especially during pandemic times and in resource limited healthcare settings. The development of portable barrier hood devices (or intubation/extubation boxes) is an area of interest for many clinicians due to the theoretical reduction in aerosolization of SARS-CoV-2, the causative virus for COVID-19.

We present a review of the current literature along with recommendations concerning safe extubation during the COVID-19 pandemic. In addition, a focused summary on the use of portable barrier hood devices, during the recent surge of COVID-19 is highlighted.

Perioperative chemoimmunotherapy in a patient with stage IIIB non-small cell lung cancer

We present a case of a 56-year-old male patient with stage IIIB (T3N2M0) poorly differentiated squamous cell carcinoma of the lung. Four cycles of chemotherapy were first applied, and the patient had stable disease. However, the patient refused to receive radiotherapy, therefore second-line treatment chemotherapy combined with anti-PD-1 immunotherapy was applied. Partial response was reached at the 4^th cycle of chemotherapy combined with anti-PD-1 immunotherapy. The neoadjuvant strategy was prolonged to 10 cycles but no significant change was observed on tumor size. The patient then underwent video-assisted thoracoscopic left lower lobectomy. Eight cycles of adjuvant PD-1 immunotherapy were applied postoperatively. Perioperative immunotherapy demonstrated good curative effect in this patient and no recurrence was observed at the clinic 40 months following surgery. Here we intend to explore the concept of immunotherapy combined with chemotherapy and surgery in neoadjuvant and adjuvant setting, and to investigate the possibility of extending this strategy in patients with stage IIIB non-small cell lung cancer (NSCLC).

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Enterovascular Fistula: An Under-Recognized Complication Related to Therapy for Esophageal Carcinoma

Background and Objectives: The formation of a fistula between the gastrointestinal tract and cardiovascular system is a rare but devastating condition. Although clinical diagnosis is suspected, autopsy confirmation is rarely obtained. Advancement in the treatment of esophageal cancer could result in an increased risk of enterovascular fistula formation. We describe autopsy-proven series of enterovascular fistulas with particular focus on this complication developing as a consequence of esophageal cancer therapy. Methods: Cases of enterovascular fistulas were retrospectively identified in the institutional autopsy case records (1994-2017). Relevant clinical information and pathologic findings were reviewed. Results: Nine cases were identified. Seven out of 9 were related to malignancy, with 6/9 occurring in the setting of treated esophageal carcinoma. This esophageal cancer group was a unique set of patients (age median: 71 years) with male predominance (M:F-5:1) presenting with hematemesis as the main symptom. All patients had advanced disease at diagnosis and the complication generally occurred late after treatment (mean interval: 1.7 years). The fistula site was between the esophagus and variety of vascular structures. The most common etiology was tumor invasion (4/6). The diagnosis of enterovascular fistula was made postmortem in all cases. Conclusions: The development of enterovascular fistulas is a late complication of treated esophageal cancer. Tumor invasion, infection, and radiation response are the leading etiologies. Early recognition and aggressive treatment may salvage this highly morbid complication.

Management of Sarcoma Metastases to the Lung

For decades, surgical resection of pulmonary metastases has been performed; despite limited randomized data, surgery is increasingly accepted as an integral part in the management of metastatic disease. Long-term results indicate resection is potentially curative with significantly improved survival following complete resection. Recurrence, however, is not uncommon with many patients undergoing repeat resection. With advancing surgical technique and adjuvant therapies, patients with high or recurrent tumor burden are increasingly afforded disease control and potential cure. In this review, the prognostic characteristics of pulmonary metastases from sarcoma, preoperative evaluation, operative technique, long-term outcomes, and management of complex patients are highlighted.

Utility and reproducibility of 3-dimensional printed models in pre-operative planning of complex thoracic tumors

BACKGROUND AND OBJECTIVES

3D-printed models are increasingly used for surgical planning. We assessed the utility, accuracy, and reproducibility of 3D printing to assist visualization of complex thoracic tumors for surgical planning.

METHODS

Models were created from pre-operative images for three patients using a standard radiology 3D workstation. Operating surgeons assessed model utility using the Gillespie scale (1 = inferior to 4 = superior), and accuracy compared to intraoperative findings. Model variability was assessed for one patient for whom two models were created independently. The models were compared subjectively by surgeons and quantitatively based on overlap of depicted tissues, and differences in tumor volume and proximity to tissues.

RESULTS

Models were superior to imaging and 3D visualization for surgical planning (mean score = 3.4), particularly for determining surgical approach (score = 4) and resectability (score = 3.7). Model accuracy was good to excellent. In the two models created for one patient, tissue volumes overlapped by >86.5%, and tumor volume and area of tissues ≤1 mm to the tumor differed by <15% and <1.8 cm2 , respectively. Surgeons considered these differences to have negligible effect on surgical planning.

CONCLUSION

3D printing assists surgical planning for complex thoracic tumors. Models can be created by radiologists using routine practice tools with sufficient accuracy and clinically negligible variability.

Minimally Invasive Esophagectomy for Adenocarcinomas of the Gastroesophageal Junction and Distal Esophagus: Notes on Technique

In the last three decades, with the advancement of laparoscopic and thoracoscopic surgery, minimally invasive approaches for benign and malignant diseases of the esophagus have been developed and more experience is starting to accumulate across the world. Minimally invasive esophagectomy (MIE) has demonstrated acceptable lymph node retrieval, good postoperative outcomes, and low mortality. In this article, we review our preferred technique of MIE for adenocarcinomas of the gastroesophageal junction and distal esophagus.

Ataxia induced by a thymic neuroblastoma in the elderly patient

Thymic neuroblastoma is a rare tumor with only few reports in modern literature. Whereas most data is taken from childhood neuroblastoma, little is known about the characteristics of the disease in the adult and elderly population.

There are significant differences between adult and childhood neuroblastoma which are reviewed below.

We report a case of a 62-year-old male who presented with neurological symptoms of ataxia and opsoclonus and an anterior mediastinal mass. Ultimately, the patient underwent a resection of the mass and pathologic review identified a thymic neuroblastoma. This is the first case of thymic neuroblastoma associated with symptomatic central nervous system disease; it is presented with an up-to-date review of the previous cases in the field as well with a review of the literature of post adolescent neuroblastoma.

[Post-operative delirium of the elderly patient--an iceberg?]

Post-operative delirium is common, and has an incidence of 37-74% as reported in different publications. The growing rates of the elderly among surgical patients makes that condition more relevant than ever, since these populations are highly susceptible to develop this condition. Contrary to the common assumption, delirium is not a unique complication of the elderly alone. Trauma and young surgical patients may also present its manifestations after major and complicated surgery in the different intensive care units. Post-operative delirium was shown to precede long term complications such as dementia. Many of the patients that develop delirium will be sent to long and complicated rehabilitation units, after being reLeased from hospitalization, thus increasing the economic burden on the medical system. Furthermore, the once recognized "ICU Psychoses" are no longer exclusive to intensive care units alone, and nowadays, infiltrate to all surgical departments. Simple, bedside clinical tools were developed, for rapid diagnoses of post-operative delirium. Adequate and on time diagnosis of this condition is crucial in the surgical patient, as it may be the only sign that predicts other severe surgical complications. This review exposes aspects of post-operative delirium in the elderly patient. Diagnostic modalities, as well as current management recommendations are discussed.

Low probability of Significant Intra-Abdominal Injury in Stable Patients with Abdominal ''Seat Belt Sign''

STUDY OBJECTIVE

Our aim was to determine the diagnostic significance of the association between the abdominal skin bruise from a seat belt and the presence of intraabdominal injury.

METHODS

This was an observational analysis of prospectively collected data on 45 patients who presented with an abdominal seat belt sign to a level 1 trauma center following a motor vehicle accident between July 2004 and December 2007. The patients were evaluated by computed tomography (CT) scans or ultrasonography (FAST), depending on their hemodynamic stability. They were then hospitalized for treatment or observation.

RESULTS

Forty-five patients [23 males (51.1%) and 22 females (48.9%)], with a mean age of 32.2 years (range 16-80 years), fulfilled entry criteria and were enrolled. Of these, 44 (97.8%) underwent CT, and one (2.2%) underwent FAST due to hemodynamic instability. two patients (4.4%) had intraabdominal injuries: one required surgery for bowel injury, and the other had a minor liver laceration, which was managed expectantly. Sixteen patients (35.5%) had concomitant injuries. The length of hospital stay ranged from 1-23 days (median 2.2 days).

CONCLUSIONS

Despite the widely accepted view that patients with an abdominal seat belt sign are more likely to have serious intraabdominal injuries, the results of our investigation showed no such association in a group of hemodynamically stable patients.

Transneuronal retrograde viral labeling in the brain stem and hypothalamus is more intense from the left than from the right adrenal gland

Previous studies using the viral transneuronal tracing technique demonstrated central autonomic circuits involved in the innervation of the adrenal gland. Since increasing number of data indicate laterality in the neuroendocrine system, we aimed to investigate whether the supraspinal innervation of the adrenal gland exhibits asymmetry or not. The central circuitry involved in the innervation of the left and the right adrenal gland was studied in individual rats by dual transneuronal tracing using isogenic recombinant strains (Ba-DupGreen and Ba-Duplac expressing lacZ) of Bartha strain of pseudorabies virus. Viral infection of brain nuclei (dorsal vagal nucleus, nucleus of the solitary tract, caudal raphe nuclei, A5 cell group, hypothalamic paraventricular nucleus) from the left adrenal was more severe than that from the right organ. Dual-infected neurons were present both in the brain stem and in the hypothalamus. The results indicate a predominance in the supraspinal innervation of the left adrenal gland, and that each adrenal gland is innervated both by side-specific neurons and by neurons that project to both organs.

Predominance of supraspinal innervation of the left ovary

In our previous studies using the viral transneuronal tracing technique we demonstrated the spinal and supraspinal components of the ovarian innervation. Since increasing number of data indicate the presence of morphological and functional laterality in the control of gonadal functions, we aimed to investigate whether cerebral structures trans-synaptically involved in the innervation of the ovary exhibit asymmetry or not. In one of the studies the left or the right ovary was injected with the red fluorescent protein expressing pseudorabies virus and the number of infected "red" autofluorescent neurons from the right and the left ovary was compared. In another study in order to have distinct labeling of cell groups connected with the right- and left-sided ovary in the same animal, a dual viral labeling was applied. The left- and right-sided ovary were inoculated with genetically engineered pseudorabies virus expressing a red fluorescent protein or a green fluorescent protein gene. Viral infection of brain nuclei including the dorsal vagal nucleus, caudal raphe nuclei, A5 noradrenergic cell group, hypothalamic paraventricular nucleus, from the left ovary in each case was enhanced when compared with labeling from the right gonad. Data suggest a predominance in the supraspinal innervation of the left ovary.