Search

Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann–Whitney tests, and regression analyses were performed as appropriate. We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma. [ABSTRACT FROM AUTHOR]

Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures. We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications. Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death. Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications. [ABSTRACT FROM AUTHOR]

Background: Limited evidence exists assessing whether anastomotic evaluation using indocyanine green fluorescence (IGF) during minimally invasive esophagectomy (MIE) predicts or improves outcomes. We hypothesized that IGF helps surgeons predict anastomotic complications and reduces anastomotic leaks after MIE. Methods: In September 2019, our institution began routinely using IGF for intraoperative evaluation of anastomoses during MIE. Data were collected from patients undergoing MIE in the two years before and after this technology began being routinely used. Baseline characteristics and outcomes, including anastomotic leak, in patients who underwent indocyanine green fluorescence evaluation (ICG) and those who did not (nICG) were compared. Outcomes were also compared between ICG patients with normal versus abnormal fluorescence. Results: Overall, 181 patients were included. Baseline demographic and clinical characteristics did not differ between the ICG and nICG groups. ICG patients experienced higher rates of anastomotic leak (10.2% vs. 1.6%, P = .015) and 90- day mortality (8.5% vs. 1.6%, P = .04) compared to nICG patients. Due to lack of equipment availability, 19 nICG patients underwent MIE after the use of IGF became routine, and none developed leaks. ICG patients with abnormal fluorescence had higher rates of anastomotic leak (71.4% vs 1.9%, P < .001) and 30-day mortality (28.6% vs 0%, P = .012) compared to those with normal fluorescence. Discussion: Abnormal intraoperative IGF was associated with increased rate of anastomotic leak, suggesting predictive potential of IGF. However, its use was associated with an increased leak rate and higher mortality. Further studies are warranted to assess possible physiologic effects of indocyanine green on the esophageal anastomosis. [ABSTRACT FROM AUTHOR]

Simple Summary: This is an invited study for the special edition, "Role of Immunotherapy in Gastroesophageal Cancers: Advances, Challenges and Future Strategies". Esophageal cancer is a disease with one of the lowest survival rates. For patients who have resectable tumors, current guidelines recommend treatment with neoadjuvant chemoradiation followed by surgery if feasible. Recent clinical trials have suggested that treating patients with residual pathologic disease with adjuvant immunotherapy can increase overall survival. The aim of our retrospective study was to assess the real-world outcomes of patients at a regionalized esophageal cancer center in a large integrated health system. We found that the majority of patients are unable to complete immunotherapy treatment (82%), most commonly due to disease progression or side effects. In logistic regression, immunotherapy also did not significantly impact 1-year overall survival. Our experience within the first two years of adjuvant immunotherapy being introduced suggests that real-world outcomes vary greatly outside of those seen in a clinical trial. Background: Adjuvant immunotherapy has been shown in clinical trials to prolong the survival of patients with esophageal cancer. We report our initial experience with immunotherapy within an integrated health system. Methods: A retrospective cohort study was performed reviewing patients undergoing minimally invasive esophagectomy at our institution between 2017 and 2021. The immunotherapy cohort was assessed for completion of treatment, adverse effects, and disease progression, with emphasis on patients who received surgery in 2021 and their eligibility to receive nivolumab. Results: There were 39 patients who received immunotherapy and 137 patients who did not. In logistic regression, immunotherapy was not found to have a statistically significant impact on 1-year overall survival after adjusting for age and receipt of adjuvant chemoradiation. Only seven patients out of 39 who received immunotherapy successfully completed treatment (18%), with the majority failing therapy due to disease progression or side effects. Of the 17 patients eligible for nivolumab, 13 patients received it (76.4%), and three patients completed a full course of treatment. Conclusions: Despite promising findings of adjuvant immunotherapy improving the survival of patients with esophageal cancer, real-life practice varies greatly from clinical trials. We found that the majority of patients were unable to complete immunotherapy regimens with no improvement in overall 1-year survival. [ABSTRACT FROM AUTHOR]

Though limited, recent evidence supports observation rather than intervention for spontaneous pneumothorax management. We sought to compare the utilization and outcomes between observation and intervention for patients with primary and secondary spontaneous pneumothoraces. A retrospective cohort study of all adults presenting to Kaiser Permanente Northern California emergency rooms with spontaneous pneumothorax from 2016 to 2020 was performed. Those with prior pneumothoraces, tension physiology, bilateral pneumothoraces, effusions, and prior thoracic procedures or surgery on the affected side were excluded. Groups included observation versus intervention. Baseline clinicodemographic variables and outcomes were compared. Treatment was considered successful if further interventions were not required for pneumothorax resolution. Wilcoxon rank-sum tests, chi-square tests, Fischer exact tests, and multivariable logistic regression models were performed. Of the 386 patients with primary spontaneous pneumothorax, age, race/ethnicity, body mass index, smoking status, and the Charlson comorbidity index were not different between treatment groups. Of 86 patients with secondary spontaneous pneumothorax, age, gender, and smoking status were not different between treatment groups. Among patients with primary pneumothoraces, 83 underwent observation while 303 underwent intervention. The success rate was 92.8% for observation and 60.4% for intervention (P < 0.0001). Among patients with secondary pneumothoraces, 15 underwent observation while 71 underwent intervention, with a successful rate of 73.3% for observation and 32.4% for intervention (P = 0.003). Given the high success rates for observation of both small and moderate primary and secondary pneumothoraces, observation should be considered for clinically stable patients. Observation may be the superior choice for decreasing morbidity and healthcare costs. • Observation is successful for both primary and secondary spontaneous pneumothoraces. • Observation is associated with successful resolution regardless of pneumothorax size. • Observation could help decrease morbidity and healthcare costs. [ABSTRACT FROM AUTHOR]

Background: Optimal time to surgery for lung cancer is not well established. We aimed to assess whether time to surgery correlates with outcomes. Methods: We assessed patients 18–84 years old who were diagnosed with stage I/II lung cancer at our integrated healthcare system from 2009 to 2019. Time to surgery was defined to start with disease confirmation (imaging or biopsy) prior to the surgery scheduling date. Outcomes of unplanned return to care within 30 days of lung cancer surgery, all-cause mortality, and disease recurrence were compared based on time to surgery before and after 2, 4, and 12 weeks. Results: Of 2861 included patients, 70% were over 65 years old and 61% were female. Time to surgery occurred in 1–2 weeks for 6%, 3–4 weeks for 31%, 5–12 weeks for 58%, and 13–26 weeks for 5% of patients. Patients with time to surgery > 4 (vs. ≤ 4) weeks had greater risk of both death (hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.00–1.39) and recurrence (HR 1.33, 95% CI 1.10–1.62). Associations were not statistically significant when dichotomizing time to surgery at 2 or 12 weeks for death (2 week HR 1.23, 95% CI 0.93–1.64; 12 week HR 1.35, 95% CI 0.97–1.88) and recurrence (2 week HR 1.54, 95% CI 0.85–2.80; 12 week HR 2.28, 95% CI 0.80–6.46). Conclusions: Early stage lung cancer patients with time to surgery within 4 weeks experienced lower rates of recurrence. Optimal time to surgical resection may be shorter than previously reported. [ABSTRACT FROM AUTHOR]

Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic. We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann–Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality. During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02). Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes. [ABSTRACT FROM AUTHOR]

Simple Summary: This is an invited review for the special edition, "Minimally Invasive Surgery for Cancer: Indications and Outcomes." Indications to perform minimally invasive techniques for esophagectomy rather than the classic open technique do not exist. This review outlines the current research by comparing outcomes among minimally invasive esophagectomy, robot-assisted esophagectomy, and open esophagectomy. After determining the benefits of each technique in terms of each outcome, the discussion focuses on how surgeons may use the presented information to determine which approach is most appropriate. We hope this study provides a comprehensive review of the current state of the literature regarding minimally invasive esophagectomy, as well as a guide for surgeons who treat patients with esophageal cancer. With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach. [ABSTRACT FROM AUTHOR]

A 50-year-old male with history of HIV, syphilis, paraneoplastic Morvan syndrome secondary to thymoma resected in 2013 presented recently with tachycardia, tremors, diarrhea, hyperhidrosis and bilateral lower extremity pain leading to the discovery of thymoma recurrence. He initially developed Morvan Syndrome after thymectomy in 2013 and gradually improved with negative anti-contactin-associated protein-like 2 antibody testing in 2017 and symptom resolution in 2018. Upon return of dysautonomia symptoms, subsequent imaging revealed widespread disease recurrence diffusely in the right lung parenchyma and pleura for which he underwent right extrapleural pneumonectomy. He was managed with low-dose prednisone perioperatively, but when his symptoms worsened, he was started on rituximab and methylprednisolone. Nearly 3 months from surgery, he died from urinary sepsis. This represents a unique case of recurrent paraneoplastic Morvan syndrome leading to the diagnosis of metastatic thymoma as well as the challenges of symptom control during the surgical management of the underlying disease. [ABSTRACT FROM AUTHOR]

Limited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients. Multiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U -tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission. We identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302). Although multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population. [ABSTRACT FROM AUTHOR]

A 29-year-old male developed acute onset severe shortness of breath and fevers and was found to have a 17 cm anterior mediastinal mass with immature teratoma and possible mixed germ cell tumor on biopsy. He remained hospitalized during neoadjuvant cisplatin-based chemotherapy due to compressive symptoms from his mass and neutropenic fevers. Despite 3 cycles of therapy, his tumor mildly increased in size. After multidisciplinary discussion, he underwent urgent en bloc resection with a right hemi-clamshell incision. His postoperative course was uncomplicated and he was discharged to home within a week. His final pathology demonstrated mixed germ cell tumor. [ABSTRACT FROM AUTHOR]

Background: A few observational studies have found that outcomes after esophagectomies by thoracic surgeons are better than those by general surgeons. Methods: Non-emergent esophagectomy cases were identified in the 2016-2017 American College of Surgeons NSQIP database. Associations between patient characteristics and outcomes by thoracic versus general surgeons were evaluated with univariate and multivariate logistic regression. Results: Of 1,606 cases, 886 (55.2%) were performed by thoracic surgeons. Those patients differed from patients treated by general surgeons in race (other/unknown 19.3% vs 7.8%; P<.001) but not in other baseline characteristics (age, sex, BMI, and comorbidities). Thoracic surgeons performed an open approach more frequently (48.9% vs 30.8%, P<.001) and had operative times that were 30 minutes shorter (P<.001). General surgeons had lower rates of reoperation (11.8% vs 17.2%; P=.003) and were more likely to treat postoperative leak with interventional means (6.3% vs 3.4%, P=.01). Thoracic surgeons were more likely to treat postoperative leak with reoperation (5.9% vs 3.6%, P=.01). There were no other differences in univariate comparison of outcomes between the two groups, including leak, readmission, and death. General surgery specialty was associated with lower risk of reoperation. Our multivariable model also found no relationship between general surgeon and risk of any complication (odds ratio 1.10; 95% CI.86 to 1.42). Discussion: In our large, national database study, we found that outcomes of esophagectomies by general surgeons were comparable with those by thoracic surgeons. General surgeons managed postoperative leaks differently than thoracic surgeons. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Intraoperative radiation therapy (IORT) may not be as effective in the community compared with clinical trials. METHODS: The authors reviewed data from the electronic health records of patients who received IORT between February 2014 and February 2020 at a single center within a large integrated health care system. The primary outcome was ipsilateral breast tumor recurrence. RESULTS: of 5731 potentially eligible patients, 245 (4.3%) underwent IORT (mean age: 65.4 ± 0.4 years; median follow-up time: 3.5 years ± 2.2 months). according to the American Society for radiation oncology's accelerated partial breast irradiation guidelines based on final pathology, 51% of patients were suitable candidates for IORT, 38.4% were cautionary, and 10.6% were unsuitable. For adjuvant therapy, 6.5% had consolidative whole breast irradiation, and 66.4% received endocrine treatment. at the median follow-up time of 3.5 years, overall ipsilateral breast tumor recurrence was 3.7%. recurrences tended to be more frequent in patients who refused or did not complete endocrine treatment than in those who received it (7.4% vs 1.9%, p = 0.07). The complication rate was 14.7%, with seroma being the most common (8.2%). DISCUSSION: The IORT ipsilateral breast tumor recurrence rate of 3.7% confirms a higher-than-expected rate compared to randomized clinical trials, possibly due to less compliance with endocrine therapy. CONCLUSION: The authors subsequently revised their IORT protocol to require endocrine treatment as a part of the IORT treatment plan and to strongly recommend adjuvant whole breast irradiation for all patients deemed cautionary or unsuitable for IORT according to the American Society for radiation oncology's accelerated partial breast irradiation guidelines. [ABSTRACT FROM AUTHOR]

After being diagnosed with myasthenia gravis, a 55-year-old male was referred for treatment of an invasive thymoma. Preoperative imaging revealed a thymoma adjacent to the superior vena cava (SVC) with possible invasion of the left innominate vein. After multidisciplinary discussion, he underwent upfront en bloc resection of the tumor with SVC resection and reconstruction. He was discharged after an uncomplicated postoperative course with improvement of his symptoms. [ABSTRACT FROM AUTHOR]