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Introduction Stereotactic body radiation therapy (SBRT) is an effective treatment for early-stage non-small cell lung cancer (NSCLC) patients who are either medically inoperable or who decline surgery. SBRT improves tumor control and overall survival (OS) in medically inoperable, early-stage, NSCLC patients. In this study, we investigated the effectiveness of two different SBRT doses commonly used and present our institutional experience. Purpose To determine the clinical outcomes between two treatment regiments (50 Gray [Gy] vs. 55 Gy in five fractions) among Stage I NSCLC patients treated with SBRT at a state academic medical center. Methods We performed a retrospective analysis of 114 patients with Stage I (T1-2 N0 M0) NSCLC treated at a state academic medical center between October 2009 and April 2019. Survival analyses with treatment regimens of 50 Gy and 55 Gy in five fractions were conducted to detect any improvement in outcomes associated with the higher dose. The primary endpoints of this study included OS, local control (LC), and disease-free survival (DFS). Log-rank test and the Kaplan-Meier method were used to analyze the survival curves of the two treatment doses. The SPSS v.24.0 (IBM Corp., Armonk, NY, USA) was used for statistical analyses. Results The 114 early-stage NSCLC patients (median age, 68 years; range 12 to 87 years) had a median follow-up of 25 months (range two to 86 months). The number of males (n = 72; 63.2 %) exceeded the number of females (n = 42; 36.8 %). The majority of patients in this study were Caucasians (n = 68; 59.6 %) and 46 patients were African Americans (40.4 %). Two-thirds of the patients (n = 76; 66.7 %) were treated with 50 Gy in five fractions, and 38 patients (33.3 %) with 55 Gy in five fractions. The one-, two-, and three-year OS and DFS rates were improved in the patients treated with 55 Gy [OS, 81.7 % vs. 72.8 %; 81.7 % vs. 58.9 %; 81.7 % vs. 46.7 % (p = 0.049)], [DFS, 69.7 % vs. 69.7 %; 61.9 % vs. 55.7 %; 61.9 % vs. 52.0 % (p = 0.842)], compared to those treated with 50 Gy. Adenocarcinoma was the most common histology in both groups (51.3 % and 68.4 %). Failure rates were elevated for the 50 Gy regimen [39 (34.2 %) vs. 12 (8.5 %)]. Three year control rates were (66.3 % vs. 96.6 %; p = 0.002) local control; (63.3 % vs. 94.4 %; p = 0.000) regional control; and (65.7 % vs. 97.1 %; p = 0.000) distant control, compared to those treated with 55 Gy. Conclusion Early-stage NSCLC patients treated with SBRT 55 Gy in five fractions did better in terms of local control, overall survival, and disease-free survival rates compared to the 50 Gy in five fractions group.

We describe the management of a large bronchoesophageal fistula secondary to Hodgkin lymphoma with a fully covered self-expanding metallic stent.

Objective: Gastric outlet obstruction is common after esophagectomy. Our goal was to determine the incidence of gastric outlet obstruction after esophagectomy with or withoutpyloromyotomy and analyzeits management by endoscopic pyloric dilatation.Methods:Two hundredfortytwo patientsunderwentesophagectomy with gastricconduit fromJanuary 2002to June 2006.Subjects were dividedintotwo groups:GroupA had no pyloromyotomy (n = 83) and Group B had a pyloromyotomy (n = 159). Gastric outlet obstruction was strictly defined to include patients with clinical delayed gastric emptying supported by symptoms, barium swallow studies, persistent air—fluid level and dilated conduit on radiography, or endoscopic or surgical intervention to improve gastric drainage. Results: The groups were similar except for a higher percentage of cervical anastomosis and olderage (64- vs 61-year-old) in Group A. The overallincidenceof gastric outlet obstruction was 15.3% (37/242). Pyloromyotomy did not reduce the incidence of gastric outlet obstruction (Group A 9.6% vs Group B 18.2%, p = 0.078). One patient required a late pyloroplasty. Successful management of gastric outlet obstruction with pyloric dilatation (96.7%, 28/29) was unaffected by pyloromyotomy. There was no difference in length of stay, pneumonia (Group A 27.7% vs Group B 19.5%, p = 0.15), respiratory failure or anastomotic stricture. There was no difference in anastomotic leaks when controlling for the anatomic location of the anastomosis (p = 0.36). Mortality was equivalent between groups (2.4 vs 2.5%, p = 0.96). Conclusion: Pyloromyotomy does not reduce the incidence of symptomatic delayed gastric emptying after esophagectomy. Post-operative gastricoutletobstructioncan beeffectivelymanagedwith endoscopicpyloricdilatation.Routine pyloromyotomy for the prevention of post-esophagectomy gastric outlet obstruction may be unwarranted. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy. Methods This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU). Results Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months. Conclusions Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.

Background Obstruction of the superior vena cava (SVC) by tumor or benign disease implies unreconstructable disease and poor outcome. We analyzed the operative results, graft patency, and survival in patients undergoing SVC resection and reconstruction for benign disease and pulmonary or mediastinal malignancy. Methods Patients undergoing SVC resection from 1997 to 2007 for surgical management of benign and invasive neoplasms were retrospectively reviewed. Results We identified 19 patients requiring SVC resection. Malignant disease was resected in 17: lung cancer in 9 and mediastinal malignancy in 8. Two patients (10%) with benign processes required reconstruction for chronic SVC syndrome. Ringed Gore-Tex conduit (W. L. Gore and Associates, Flagstaff, AZ) was used for 12 reconstructions (63%) of the SVC, and 7 patients underwent primary closure or autologous pericardial patch repair. Preoperative chemoradiotherapy was administered to 9 patients (53%). There was one perioperative death (5%). Major postoperative morbidities included atrial fibrillation in 5, stroke in 2, respiratory failure in 3, myocardial infarction in 1, and Horner syndrome in 1. Median survival for the entire cohort was 45.5 months (range, 0.2 to 147 months), with a mean follow-up of 45.8 months. Five-year survival probability was 30% for patients with resected lung cancer and 56% for patients with resected anterior mediastinal malignancies. Conclusions Resection and reconstruction may be safely performed in selected patients for benign and malignant obstruction or infiltration of the SVC. Survival and intermediate-term patency after tubular grafting of the SVC are acceptable.

Background: Complications following colon interposition may be acute or chronic and often devastating. Creative strategies are needed to preserve the conduit or develop alternatives when the conduit cannot be salvaged. Methods: The records of patients undergoing revision surgery of colon interposition between 1965 and 2005 were reviewed. Results: Thirty-five patients underwent 48 operative revisions. Nineteen patients underwent one operation, nine required multiple operations to manage one problem and seven developed more than one distinct problem requiring several operative interventions. The mostcommon indications for revision surgery were redundancy (n = 13), stricture (n = 11), and loss of intestinal continuity (n = 8). The most common revisional operations were anastomotic revision (n = 13), segmental colonic resection (n = 6), and stricturoplasty (n = 4). Swallowing function was restored in 32 of 35 patients. Loss of intestinal continuity was successfully reversed in six of sevenpatients.Therewerenointraoperativedeaths.Fourpatientsrequiredre-operationaftera failedrevisionatourinstitution.Swallowingwas restored in three of four patients. Conclusions: Complications that develop after colon bypass present major challenges for surgeons to maintain swallowing and quality of life. We present successful strategies to manage these devastating complications. It is the largest report dealing with a wide variety of complications of colon bypass. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Can Gastric Stimulation in an Animal Model Effect Duodenal and Sphincter of Odi Electrical Activity? a Pilot Study Utilizing Ancillary High Resolution Recordings Thomas L. Abell*, Benjamin T. Boatright, Brittain F. Heindl, Sumanth Daram, Simon H. Bull, Zeke Pullan, Archana Kedar, Pierre De Delva, Christopher J. Lahr, Warren Starkebaum, Peng Du, Leo K. Cheng Digestive Diseases, University of Louisville Medical Center, Louisville, KY; Digestive Diseases, University of Mississippi Medical Center, Jackson, MS; Surgery, University of Mississippi Medical Center, Jackson, MS; Medicine, University of Alabama Birmingham, Birminham, AL; Bioengineering, University of Auckland, Auckland, New Zealand; Consultant Engineer, Plymouth, MN Introduction: Many patients with the symptoms of gastroparesis (Gp), who have known electro-mechanical dysfunction, also have concomitant biliary symptoms. Although the mechanism remains unknown, abnormalities similar to those seen with gastric electrical function might also exist in the biliary tree. We utilized an animal model to investigate a possible connection between gastric and biliary electrical activity utilizing stimulation of the stomach while measuring simultaneous biliary electrical activity. High resolution recordings of electrical activity are a new technology that has not been widely used, especially regarding neural stimulation of the gut. Methods: Utilizing three pigs as the model, the stomach was stimulated with 3 electrical energies, labeled as low, medium and high, and simultaneously recorded the evoked response of electrical activity in the biliary tree, via electrodes in the sphincter of Oddi and duodenal regions. Using this model with electrodes attached surgically, the three energies (as energy/pulse in micro-jules) utilized the following settings: Low (5 mA of current, Pulse Width (PW) 330 microseconds, 14 Hz, 0.1 s on and 5 s off), Medium (10 mA of current, PW 330 microseconds, 28 Hz, 1.0 s on and 4.0 s off) and High (20 mA, PW 450 microseconds, 55 Hz, 4 s on and 1.0 s off). Sphincter of Oddi and duodenal electrical activities were recorded and analyzed by signal averaging for frequency (in cpm), amplitude (in mV) and frequency to amplitude ratio (FAR). In addition, high resolution mapping using a multi-electrode array recorded electrical activity in adjacent areas. Descriptive statistics, including comparisons with energies used, were performed and reported as mean values. Results: Using the model and methods above, delivery of low, medium and high energies via the stomach resulted in changes in frequency and amplitude in the biliary tree with the most optimal values (by lowest FAR) after stimulation being at the highest energies (see table one). Simultaneous high resolution recordings were also recorded and baseline frequncies were similar (10.0 cpm for signal averaging and 9.8 cpm for high resolution recordings.) Conclusions: Gastric stimulation in an animal model appears to effect biliary (sphincter of Oddi and duodenal) electrical activity. Simultaneous high resolution electrical recordings also are feasible and may be applied to this model.This data suggests the existence of intrinsic neural connections that could have potential for therapeutic use in patients with Gp and biliary dyskinesia.