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Adequate reconstruction of sternal defects is critical for function and quality of life. Reconstructive techniques have historically included a rigid component, most often a synthetic prosthesis, but these are associated with complications related to presence of a foreign body and the loss of native bone's flexibility and growth capability. Recently, biologic mesh has been used as an alternative for reconstructions of the chest wall, but not the sternum. We present the case of a large sternal defect after chondrosarcoma resection reconstructed with porcine acellular dermal matrix and soft tissue flaps, without rigid component, and with excellent patient outcome through 2 years of follow-up.

BACKGROUND: Some studies have found that outcomes from cancer esophagectomy are better at higher-volume centers than at lower-volume centers. Reports on outcomes following systematic centralization have largely demonstrated subsequent improvements, but these originate in nationalized healthcare systems that are not very comparable to the heterogeneous private-payer systems that predominate in the United States. We examined how regionalization of thoracic surgery to Centers of Excellence (CoE) within our American integrated healthcare system changed overall care for our patients, and whether it changed outcomes. METHODS: We conducted a retrospective chart review of 461 consecutive patients undergoing cancer esophagectomy between 2009–2016, spanning the 2014 shift to regionalization. High-volume was defined as ≥5 esophagectomies per year. We compared characteristics of the surgeon, hospital, and operation pre- and post-regionalization using Chi-square or Fisher’s exact test for categorical variables and Kruskal-Wallis test for age. We evaluated their associations with patient outcomes with hierarchical linear and logistic mixed models, which adjusted for clustering within surgeon and facility levels and relevant covariates. RESULTS: While there was no difference in their baseline demographics, patients undergoing esophagectomy post-regionalization were much more likely to have their surgery performed at a designated Center of Excellence (78.8% of cases versus 34.2%, P

Mucor is a ubiquitous fungus that is non-pathogenic in healthy people. In immunocompromised hosts, nonfunctional or absent neutrophils and macrophages result in fungal invasion and infection [1]. Invasive mucor (mucormycosis) most commonly involves the sinuses, brain, or lungs. Pulmonary mucormycosis typically presents in patients with a history of organ transplantation or hematologic malignancy [2], and is rare in patients with diabetes alone. The epidemiology and management of pediatric pulmonary mucormycosis is poorly described. We report an unusual occurrence of this disease, complicated by segmental pulmonary artery thrombus in a 15-year-old with poorly controlled diabetes. His severe, medication-resistant infection was ultimately treated successfully with antifungal medication combined with aggressive surgical debridement. The pulmonary artery segmental thrombus resolved after treatment of the underlying infection without anticoagulation. Keywords: Mucormycosis, Pulmonary mucormycosis, Diabetes, Pneumonectomy, Clagett procedure, Pediatric thoracic surgery

Context Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported. Objective To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel. Design Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%). Main outcome measure Presence of postoperative lung air leak. Results No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414). Conclusion Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.

Tietze syndrome is a rare and benign cause of chest pain that may be confused with life-threatening conditions. Characteristic findings are painful, localized inflammation of the costosternal, sternoclavicular, or costochondral joints typically of the second and third ribs. We present a patient with severe, medically refractory symptoms consistent with Tietze syndrome. Although surgical management is not the typical treatment course, symptomatic control was eventually achieved with complete resection of the involved cartilage and adjacent rib. We propose surgical management in patients with debilitating cases of Tietze syndrome that are resistant to conservative therapies.

Current literature favors a volume-outcome relationship in pulmonary lobectomy that prompted centralization of these operations abroad, in national, single-payer health care settings. This study examined the impact of regionalization on outcomes after lung cancer resection within a US integrated health care system.This study retrospectively reviewed major pulmonary resections (lobectomy, bilobectomy, pneumonectomy) for lung cancer that were performed before (2011 to 2013; n = 782) and after (2015 to 2017; n = 845) thoracic surgery regionalization during 2014.Case migration from 16 regionwide sites to 5 designated centers was complete by 2016. Facility volume increased from 17.4 to 48.3 cases/y (P = .002), and surgeon volume increased from 12.5 to 19.9 cases/y (P = .001). The postregionalization era was characterized by increased video-assisted thoracoscopic surgery (86% from 57%; P.001), as well as decreased intensive care unit use (-1.0 days; P.001) and hospital length of stay (-3.0 days; P.001). Postregionalization patients experienced fewer total (26.2% from 38.6%; P.001) and major (9.6% from 13.6%; P = .01) complications. The association between regionalization and decreased length of stay and morbidity was independent of surgical approach and case volume in mixed multivariate models.After the successful implementation of thoracic surgery regionalization in our US health care network, pulmonary resection volume increased, and practice shifted to majority video-assisted thoracoscopic surgery and minimum intensive care unit utilization. Regionalization was independently associated with significant reductions in length of stay and morbidity.

Postsurgical pain control can have a significant impact on patient outcomes and hospital-associated costs. We sought to evaluate the effect of intercostal nerve blocks using liposomal bupivacaine on length of stay (LOS) in patients undergoing video-assisted thoracoscopic surgery (VATS).We retrospectively reviewed outcomes in 80 patients undergoing VATS wedge resection, VATS lobectomy, or minimally-invasive esophagectomy (MIE). Patients received either liposomal bupivacaine (n=40) or standard-release bupivacaine with epinephrine (n=40) via intercostal nerve block. The LOS, 24-hour postoperative pain scores, overall opioid usage, and patient ambulation rates at 24 hours were compared for the two groups.The median LOS was significantly shorter in patients receiving liposomal bupivacaine, at 1.35 days (IQR, 1.28 to 1.53 days) compared to 2.45 days (IQR, 2.08 to 3.51 days) in patients receiving standard-release bupivacaine (P0.0001). Average post-operative pain score during the first 24 hours was 3.4±1.8 for the liposomal bupivacaine group and 2.3±1.2 for the control group (P=0.002). This difference, though statistically significant, is likely not clinically significant, as there was no difference in 24-hour postoperative intravenous morphine equivalent usage between the liposomal bupivacaine and control groups (29.8±21.0The use of liposomal bupivacaine is associated with decreased LOS in postoperative thoracic surgery patients and earlier return to ambulation. It does not, however, decrease 24-hour postoperative pain scores or opioid usage.

INTRODUCTION Tracheoinnominate fistula, a rare complication of tracheostomy, carries high mortality regardless of treatment; therefore prevention and quick diagnosis is pertinent to survival. CASE PRESENTATION A 76-year-old man who underwent emergent tracheostomy placement presented on postoperative day 10 with massive hemorrhage concerning for tracheoinnominate fistula and was treated with median sternotomy and ligation of the innominate artery. DISCUSSION This presentation describes a concise diagnosis and treatment plan for a rare event. The key to good outcomes is quick diagnosis and urgent surgical intervention.

Background Many patients with ischemic heart disease have cardiovascular risk factors such as cigarette smoking. We tested the effect of nicotine (a key component of cigarette smoking) on the therapeutic effects of human embryonic stem cell-derived endothelial cells (hESC-ECs). Methods and results To induce endothelial cell differentiation, undifferentiated hESCs (H9 line) underwent 4-day floating EB formation and 8-day outgrowth differentiation in EGM-2 media. After 12 days, CD31(+) cells (13.7+/-2.5%) were sorted by FACScan and maintained in EGM-2 media for further differentiation. After isolation, these hESC-ECs expressed endothelial specific markers such as vWF (96.3+/-1.4%), CD31 (97.2+/-2.5%), and VE-cadherin (93.7+/-2.8%), form vascular-like channels, and incorporated DiI-labeled acetylated low-density lipoprotein (DiI-Ac-LDL). Afterward, 5x10(6) hESC-ECs treated for 24 hours with nicotine (10(-8) M) or PBS (as control) were injected into the hearts of mice undergoing LAD ligation followed by administration for two weeks of vehicle or nicotine (100 microg/ml) in the drinking water. Surprisingly, bioluminescence imaging (BLI) showed significant improvement in the survival of transplanted hESC-ECs in the nicotine treated group at 6 weeks. Postmortem analysis confirmed increased presence of small capillaries in the infarcted zones. Finally, in vitro mechanistic analysis suggests activation of the MAPK and Akt pathways following activation of nicotinic acetylcholine receptors (nAChRs). Conclusions This study shows for the first time that short-term systemic administrations of low dose nicotine can improve the survival of transplanted hESC-ECs, and enhance their angiogenic effects in vivo. Furthermore, activation of nAChRs has anti-apoptotic, angiogenic, and proliferative effects through MAPK and Akt signaling pathways.