Search

OBJECTIVES To estimate gender disparities among first and last authorships in cardiothoracic randomized controlled trials (RCTs) and association of gender with publications in high-impact journals. METHODS PubMed/MEDLINE database was searched from 1 January 2014 to 31 December 2020 using R statistical software via the 'easyPubMed' package to retrieve pertinent data. The 'gender' package was utilized to determine gender using the United States Social Security Administration Baby Name Data. The percentage of female first and last authors were computed along with determining the uniqueness of the names. The association of gender and publication in high-impact peer-reviewed journals was delineated. Jonckheere's trend was computed. RESULTS The database search retrieved a total of 4820 RCTs, of which gender was encoded for the first author in 3247 (67%) RCTs, among which 911 (28%) studies had women as first authors, with a similar trend across 7 years (P   =  0.23). Gender was encoded for the last author of 3204 (66%) RCTs, of which 622 (19%) studies had women as last authors, with a similar trend across 7 years (P   =  0.45). A total of 627 studies were published in high-impact-factor journals, among which 79 (16%) studies had female first authors and 67 (13%) studies had female last authors. CONCLUSIONS There is an obvious gender disparity of first and last authors in cardiothoracic surgery-related RCTs, with a similar trend across 7 years. However, the post-hoc analysis did demonstrate a positive trend with an increase in the number of female first authors, demonstrating progress. [ABSTRACT FROM AUTHOR]

Background: The Upper Digestive Disease (UDD) Tool™ is used to monitor symptom frequency, intensity, and interference across nine symptom domains and includes two Patient-Reported Outcome Measurement Information System (PROMIS) domains assessing physical and mental health. This study aimed to establish cut scores for updated symptom domains through standard setting exercises and evaluate the effectiveness and acceptability of virtual standard setting. Methods: The extended Angoff method was employed to determine cut scores. Subject matter experts refined performance descriptions for symptom control categories and achieved consensus. Domains were categorized into good, moderate, and poor symptom control. Two cut scores were established, differentiating good vs. moderate and moderate vs. poor. Panelists estimated average scores for 100 borderline patients per item. Cut scores were computed based on the sum of the average ratings for individual questions, converted to 0-100 scale. Results: Performance descriptions were refined. Panelists discussed that interpretation of the scores should take into account the timing of symptoms after surgery and patient populations, and the importance of items asking symptom frequency, severity, and interference with daily life. The good/moderate cut scores ranged from 21.3 to 35.0 (mean 28.6, SD 3.6) across domains, and moderate/poor ranged from 47.5 to 71.3 (mean 54.5, SD 7.0). Conclusions: Panelists were confident in the virtual standard setting process, expecting valid cut scores. Future studies can further validate the cut scores using patient perspectives and collect patient and physician preferences for displaying contextual items on patient- and physician-facing dashboard. [ABSTRACT FROM AUTHOR]

Purpose: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions.Methods: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement.Results: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively.Conclusions: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach. METHODS: We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared. RESULTS: A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed. CONCLUSIONS: The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure. [ABSTRACT FROM AUTHOR]

Background: Despite the increased risk for nodal disease, definitive endoscopic resection is being increasingly offered for lesions invasive into the submucosa based on the success with intramucosal tumors. The aim of this study was to evaluate survival after esophagectomy alone for confirmed submucosal tumors after endoscopic resection.Methods: Patients from seven centers in the USA who underwent esophagectomy for submucosal tumors removed with endoscopic resection were analyzed. Nodal involvement was correlated with recurrence and survival.Results: We identified 23 patients with submucosal esophageal adenocarcinoma. Esophagectomy was performed at a median of 2 months (Interquartile range 1-3) after the endoscopic resection. There was no postoperative mortality. Positive nodal disease was seen in 26 % of patients on final pathology. At a median of 37 months (Interquartile range 25-55), 91 % of patients were alive and free of disease. The disease-specific 5-year survival was 88 %. Disease-specific 5-year survival was 67 % in patients with positive nodal metastases and 100 % in those without (p = 0.159).Conclusions: Esophagectomy is curative in the majority of patients with submucosal tumors even in the presence of nodal metastases. These data serve as a benchmark for comparison when considering extending the indications for therapeutic endoscopic resection for submucosal tumors in the future. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Length of stay (LOS) is an important measure of quality and healthcare costs. Variation occurs due to individual and institutional practices, case complexity and patient/social factors. Identification of variables affecting LOS may help develop enhanced recovery protocols. This study aims to identify factors influencing LOS following surgery for hiatal hernia, gastro-oesophageal reflux and achalasia. METHODS: We identified all patients who underwent benign foregut surgery between August 2013 and July 2014 inclusive. Data from a prospectively maintained database were collected and univariate/multivariable analyses were performed. All patients were contacted to determine their 30-day readmission rate to any hospital. RESULTS: One hundred and sixty-five patients were identified in the 12-month period; 68% underwent laparoscopic surgery and 32% open surgery. The rates of laparoscopic conversion to open surgery and operative mortality were zero. Statistically, the most significant predictor of LOS was the surgical approach. The median LOS was 2 days for laparoscopic surgery and 4 days for open surgery. Beyond the surgical approach, the following factors were significant in predicting LOS: for laparoscopic surgery patients, younger age, shorter operative time, nasogastric (NG) tube removal in the operation theatre (OT), OT exit before noon, low postoperative nausea counts and discharge to home rather than a skilled facility were associated with reduced LOS. For open surgery patients, younger age, American Society of Anesthesiologists grade I-II, urinary catheter removal before discharge, discharge to home and discharge on the weekend were associated with reduced LOS. Whether surgery was primary or reoperation did not affect LOS. The overall 30-day readmission rate was 5% (laparoscopic 3% and open 12%; P = 0.003). CONCLUSIONS: The laparoscopic surgery approach, where feasible, in the treatment of benign foregut diseases is the strongest predictor of a decreased LOS. Modifiable factors influencing LOS include OT exit time, NG tube removal in the OT, urinary catheter removal in hospital and postoperative nausea control. Any implementation of enhanced recovery pathways to optimize these factors must monitor readmission rates and complications to confirm efficacy. [ABSTRACT FROM AUTHOR]

Endoscopic resection (ER) allows for local therapy of superficial esophageal cancers. Factors reported to be associated with an increased risk of lymph node metastases in patients with adenocarcinoma are poor differentiation, lymphovascular invasion (LVI), and submucosal invasion >500 μ. The aim of this study was to determine whether depth of invasion and tumor characteristics in an ER specimen can be used to gauge the risk of lymph node metastases in patients with superficial esophageal adenocarcinoma. Patients from seven US centers that had ER of an adenocarcinoma followed by an esophagectomy were identified. The ER pathology slides were rereviewed by three experienced GI pathologists for depth of invasion, presence of LVI, and tumor differentiation. The findings from the ER specimen were correlated with the presence and number of lymph node metastases in the final esophagectomy specimen. There were 19 T1a and 23 T1b tumors. A median of 24 nodes were resected per patient. None of the T1a tumors had involved lymph nodes despite the presence of LVI in 5% and poor differentiation in 21% of patients. In contrast, 26% of T1b tumors had involved nodes. None of the four patients with submucosal invasion ≤500 μ, no LVI, and no poor differentiation had involved nodes. However, with an increasing number of risk factors, the likelihood of involved lymph nodes increased, reaching 50% when all three factors were present. Endoscopic therapy appears appropriate for intramucosal tumors and may be an option for low-risk T1b tumors. Esophagectomy is preferred for patients with submucosal invasion and one or more risk factors. [ABSTRACT FROM AUTHOR]

"Pancoast" tumors frequently require a multidisciplinary approach to therapy and are still associated with high morbidity and mortality. Due to their sensitive anatomic location, complex resections and chemoradiation regimens are typically required for treatment. Those with signs of aortic invasion pose an even greater challenge, given the added risks of cardiopulmonary bypass for aortic resection and interposition. Placement of an aortic endograft can facilitate resection if the tumor is in close proximity to or is invading the aorta. Prophylactic endografting to prevent radiation-associated aortic rupture has also been described. This case describes a 60-year-old female who presented with a stage IIIa left upper lobe undifferentiated non-small-cell carcinoma encasing the subclavian artery with thoracic aorta and bony invasion. Following carotid-subclavian bypass with Dacron, en bloc resection of the affected lung, ribs, and vertebral bodies was performed. The aorta was prophylactically reinforced with a Gore TAG thoracic endograft prior to adjuvant chemoradiation. The patient remains disease-free at more than 5 years follow-up after completing her treatment course. Endovascular stenting with subsequent chemoradiation may prove to be a viable alternative to palliation or open operative management and prevention of aortic injury during tumor resection and/or adjuvant therapy in select patients with aortic involvement. [ABSTRACT FROM AUTHOR]

OBJECTIVES Primary cardiac sarcomas are extremely rare, but aggressive, tumours. The median survival with conventional treatment is 6–12 months. Recent data suggest that a radical multidisciplinary approach may improve patient outcome. We sought to evaluate our institutional experience with these tumours. METHODS A multidisciplinary cardiac tumour programme was established 3 years ago based on the experience and support of our collaborating institution. Treatment consisted of pre- and postoperative chemotherapy, complete (R0) resection of the tumour with structural reconstruction and radiation therapy in selected cases. Left atrial tumours were resected using the cardiac autotransplantation technique. Bovine pericardium was used to reconstruct free-chamber walls or the septum. Valves were replaced by bioprostheses. A variety of autologous, allogeneic and synthetic vascular grafts were used to reconstruct the aorta, pulmonary arteries (PAs) and coronary arteries. RESULTS Seven patients (3 males), age 51 ± 11 years (35–63), underwent eight operations. Tumour sites were PAs in 2 patients, left atrium in 3, right atrium in 2 and both great vessels in 1. Complete resection was achieved in all cases. There was no operative mortality. Two patients required implantation of a permanent pacemaker. Median survival was 24 months. Three patients died of metastatic disease and 1 sudden death 7, 23, 31 and 33 months after diagnosis. Three patients are alive at 2, 8 and 33 months, in functional Class I or II. One patient developed tumour recurrence and 2 have no evidence of disease. CONCLUSIONS A radical multidisciplinary approach to cardiac sarcomas consisting of multimodality treatment and complex, technically demanding surgery, is safe and markedly improves (doubling) patient survival. [ABSTRACT FROM AUTHOR]

We compared the growth of human lung cancer cells in an ex vivo three-dimensional (3D) lung model and 2D culture to determine which better mimics lung cancer growth in patients. A549 cells were grown in an ex vivo 3D lung model and in 2D culture for 15 days. We measured the size and formation of tumor nodules and counted the cells after 15 days. We also stained the tissue/cells for Ki-67, and Caspase-3. We measured matrix metalloproteinase (MMP) levels in the conditioned media and in blood plasma from patients with adenocarcinoma of the lung. Organized tumor nodules with intact vascular space formed in the ex vivo 3D lung model but not in 2D culture. Proliferation and apoptosis were greater in the ex vivo 3D lung model compared to the 2D culture. After 15 days, there were significantly more cells in the 2D culture than the 3D model. MMP-1, MMP-9, and MMP-10 production were significantly greater in the ex vivo 3D lung model. There was no production of MMP-9 in the 2D culture. The patient samples contained MMP-1, MMP-2, MMP-9, and MMP-10. The human lung cancer cells grown on ex vivo 3D model form perfusable nodules that grow over time. It also produced MMPs that were not produced in 2D culture but seen in human lung cancer patients. The ex vivo 3D lung model may more closely mimic the biology of human lung cancer development than the 2D culture. [ABSTRACT FROM AUTHOR]

Melanoma has a known propensity for cardiac metastasis. Most cases are associated with widespread metastatic disease and multiple sites of cardiac involvement and are not appropriate for surgical resection. When there is an isolated metastasis to the heart, the melanoma tends to involve the right heart. Rarely does melanoma metastasize only to the left ventricle. We present an unusual case of isolated metastasis of melanoma to the intracavitary left ventricle. This tumor was poorly responsive to chemotherapy, and a cardiac autotransplantation technique was used to achieve complete resection with pathologically negative margins. [ABSTRACT FROM AUTHOR]

Cardiac sarcomas are rare entities. The biological behavior of cardiac sarcomas is similar to all soft-tissue sarcomas. Aggressive local growth and metastatic spread are common. Although histologic type affects behavior, survival is dependent on the histologic grade. Chemotherapy and radiation therapy are not adequate for long-term survival. Although surgery provides the best modality for local control it is limited by its inability to control distant metastatic disease. Right heart sarcomas tend to be bulky, infiltrative, cause heart failure late and metastasize early. Based on the surgical approach and clinical behavior, cardiac sarcomas can be classified as right heart sarcomas, left heart sarcomas and pulmonary artery sarcomas. Our limited - albeit the most extensive - experience with cardiac sarcomas has helped improve survival compared with chemotherapy alone. They are usually treated with chemotherapy prior to extensive resection. Left heart sarcomas tend to be more circumscribed, less infiltrative, cause heart failure early and metastasize later. They are usually treated with surgery first, given the possibility of cardiac failure. Pulmonary artery sarcomas tend to be confined to the pulmonary artery, often causing severe right heart failure and metastasize later than right heart sarcomas. They are usually treated with complete resection. Adjuvant therapy is recommended for all patients given that excellent local control is often achieved with surgery, yet long-term survival is often poor due to metastatic recurrence. Cardiac autotransplantation is an excellent technique for resection of posterior or left heart cardiac sarcomas. Surgical outcomes with cardiac autotransplantation are excellent in patients who do not require concurrent pneumonectomy. Pulmonary artery sarcomas allow for radiation therapy in addition to chemotherapy for neoadjuvant control, as the myocardium can be avoided. However, overall, long-term survival after cardiac sarcoma requires improved systemic control. This progress awaits the development of novel chemotherapeutics. [ABSTRACT FROM AUTHOR]

The article discusses various aspects of diagnosis and treatment of pulmonary artery (PA) sarcoma. The article reports that primary pulmonary artery sarcoma is an unusual subset of cardiac sarcomas. It is stated that clinical presentation of patients with PA sarcoma can be easily misunderstood with other entities that affect pulmonary circulation. PA sarcoma is a very aggressive disease and the survival rate is very disappointing. It is stated that chemotherapy and radiation therapy donot work effectively in such cases.

Background: The purpose of this study was to establish the clinical thresholds for five domains (dysphagia, reflux, dumping-hypoglycemia, dumping-GI symptoms, pain) to support the use of the CONDUIT questionnaire as a screening tool to identify patients who might benefit from an educational or clinical intervention. Methods: A panel of 16 experts met to develop descriptions of "poor," "moderate," and "good" conduit performance. They were trained to use the modified and extended Angoff standard-setting method. Each judge provided item ratings that reflected borderline good and borderline moderate patients. The average item ratings were summed and transformed to a 0–100 scale to derive final cut scores. Panelist evaluation of the process and confidence with the rating tasks were collected. Results: Panelists expressed that the training on the method gave them information they needed to complete their assignment. Among other factors, their experience with patients was most influential on their ratings. On the 0–100 score scale, good/moderate cuts ranged from 7.2 to 20.8, and moderate/poor cuts ranged from 37.9 to 64.3, depending on domains and weights. Standard errors of one or both cut scores increased for dysphagia and dumping-GI with weighting. Conclusions: We described the selection and training of panelists and panelists' evaluations of the processes they were asked to follow in detail to defend the cut scores. Further prospective validation studies are underway to compare cut scores from this study and clinicians' judgments and further refine the categorization. [ABSTRACT FROM AUTHOR]

Background: Health-related quality of life (QoL) deteriorates immediately after esophagectomy. Patients may benefit from periodic assessments to detect increased morbidity on the basis of subjective self-reports. Using input from patients and health care providers, we developed a brief prototype for the esophageal conduit questionnaire (Mayo Clinic Esophageal Conduit Outcomes Noting Dysphagia/Dumping, and Unknown outcomes with Intermittent symptoms over Time after esophageal reconstruction [CONDUIT] Report Card) and previously used it in comparative research. The present study aimed to expand its content and establish health-related QoL and symptom domains of a patient-reported postesophagectomy conduit evaluation tool.Methods: We expanded tool content by selecting items measuring patient-reported symptoms from existing questionnaires or written de novo. A multidisciplinary group of clinician content-matter experts approved the draft tool, together with a designated patient advocate. The expanded tool was administered to patients postesophagectomy from March 1 to November 30, 2016. We established domains of conduit performance for score reporting through data analysis with exploratory factor analyses. We assessed psychometric properties such as dimensionality, internal consistency, and inter-item correlations in each domain and compared content coverage with other existing measures intended for this patient population. For data that were missing less than 50% of patient responses, the missing values were imputed.Results: Five multi-item domains were established from data of 76 patients surveyed after esophagectomy; single items were used to assess stricture and conduit emptying. For every multi-item domain, dominance of 1 factor was present. Internal consistency reliability estimates for the domains were 0.87, 0.78, 0.75, 0.80, and 0.83 and average inter-item correlations were 0.40, 0.50, 0.40, 0.33, and 0.73 for dysphagia, reflux, dumping-gastrointestinal symptoms, dumping-hypoglycemia, and pain, respectively. Some items observed to have lower inter-item correlation were reworded or flagged for removal at future validation. For reflux and dumping-related hypoglycemia, additional items were written after these analyses.Conclusions: The CONDUIT Report Card is a novel questionnaire for assessing QoL and symptoms of patients after esophageal reconstruction. It covers major symptoms of these patients and has good content validity and psychometric properties. The tool can be used to help direct patient care, guide intervention, and compare efficacy of different treatment options.Trial Registration: ClinicalTrials.gov identifier No. 02530983 on 8/18/2015. [ABSTRACT FROM AUTHOR]

The author discusses aspects of the article written by Zachary Kon and Linda Martin on thoracic metastases from sarcoma. He states that the paper provides a succint and complete review of published outcomes for the treatment of patients with sarcomatous pulmonary metastases. He stresses that there is no available biomarkers to predict which patients will benefit from an aggressive therapeutic approach.