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The article discusses extracorporeal membrane oxygenation (ECMO), the procedure which saves patients life, when they fail to get conventional support. The study includes review of the patients requiring ECMO for respiratory failure. The result concluded that ECMO bleeding complications can be managed successfully via surgical and endoscopic approaches in high-risk population.

John Young Templeton III was born in 1917 in Portsmouth, Virginia, and graduated from Jefferson Medical College in 1941. He completed his residency training under Dr. John H. Gibbon, Jr., and was the first resident who worked on Gibbon's heart-lung machine. After his training, he remained at Jefferson as an American Cancer Society fellow and Damon Runyon fellow and went on to become the fourth Samuel D. Gross Professor and Chair of the Department of Surgery in 1967. Dr. Templeton was the recipient of numerous grants and published over 80 papers in the field of cardiothoracic surgery. As a teacher and mentor, he was a beloved figure who placed great faith in his residents. He participated in over 60 professional societies, serving as president to many such as the Philadelphia Academy of Surgery and the Pennsylvania Association of Thoracic Surgery. He was also recognized through his many awards, in particular the John Y. Templeton III lectureship established in 1980 at Jefferson of whom Denton Cooley was the first lecturer. Dr. Templeton retired from practice in 1987. He is forever remembered as an important model of a modern surgeon evident in numerous academic achievements, the admiration and affection of his trainees, and the lives of patients that he had touched. [ABSTRACT FROM AUTHOR]

Background: The ACS-NSQIP Colectomy-Targeted database provides valuable metrics on surgical outcomes by utilizing clinical data to enhance quality improvement efforts. However, the quality measures offered in the ACS-NSQIP semiannual report do not stratify for the indication for colectomy. We aim to compare postoperative outcomes in patients undergoing colectomy for colon cancer, infectious causes, and inflammatory bowel disease (IBD)., Study Design: A retrospective review of patients undergoing colectomy was performed using the ACS-NSQIP Colectomy-Targeted database from 2012-2022. Logistic regression models were used to compare the 30-day postoperative outcomes of patients who underwent colectomy for colon cancer, infectious causes, and IBD while adjusting for pre-operative risk factors., Results: There were 158,560 patients who underwent colectomy for colon cancer, 90,827 patients for infectious causes, and 30,548 patients for IBD. In unadjusted analysis, patients undergoing colectomy for infectious causes had the highest rates of mortality (2.6%) and morbidity (27.6%). After adjusting for covariates, IBD patients undergoing colectomy had significantly higher odds of morbidity compared to those undergoing colectomy for colon cancer (OR 1.3, 95% CI [1.1, 1.4]) and infectious causes (OR 1.3, [1.2, 1.4]). Furthermore, IBD patients had significantly higher odds of experiencing venous thromboembolism, surgical site infections, prolonged ileus, and readmission within 30 days compared to both colon cancer and infectious causes patients., Conclusions: This study demonstrates that the indication for colectomy impacts postoperative outcomes. Reporting risk-adjusted outcomes based on the underlying disease etiology could lead to identifying high-risk patients, improving benchmarking outcomes, and developing targeted quality initiatives., (Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: In response to the opioid epidemic, prescribing guidelines and statewide surgical opioid management programs were initiated in 2018-19. This analysis aims to document the sustainability of a regional opioid stewardship consortium through the pandemic and beyond., Study Design: From September 2019 through August 2023, 15 NSQIP hospitals in two states gathered opioid-specific variables on patients undergoing 12 procedures. Operations were performed by seven specialties including general surgery, gynecology, orthopedic surgery, neurosurgery, surgical oncology, urology, and vascular surgery. Data were gathered on preoperative opioid use, intraoperative opioids and blocks, opioid avoidance strategies and discharge opioid prescriptions. Cochran-Armitage trend and Wald tests were utilized to assess temporal effects with p values <0.001 considered significant., Results: Among 18,325 patients who underwent surgery, 54% were women, with a median age of 60 years. The percentage of patients taking opioids preoperatively decreased significantly (p<0.001) in the overall cohort from 17% to 10%. The utilization of intraoperative blocks also increased significantly (p<0.001) among all patients from 21% to 27%. The utilization of opioid avoidance strategies was maintained in the majority of the patients (68-70%) and the percentage of postoperative opioid prescriptions on discharge remained the same (81%) over the four-year study period., Conclusion: From 2019 to 2023, the percentage of patients taking opioids preoperatively decreased significantly, and the utilization of intraoperative blocks also increased significantly. The PENNJ-SOS program played a key role in combatting the opioid crisis over the four years of data collection, adapting effectively to the challenges posed by the Coronavirus Disease 2019 pandemic., (Copyright © 2025 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postoperative opioid abuse following surgery is a major concern. This study sought to create an opioid reduction toolkit to reduce the number of narcotics prescribed and consumed while increasing awareness of safe disposal in pancreatectomy patients., Methods: Prescription, consumption, and refill request data for postoperative opioids were collected from patients receiving an open pancreatectomy before and after the implementation of an opioid reduction toolkit. Outcomes included safe disposal practice awareness for unused medication., Results: 159 patients were included in the study: 24 in the pre-intervention and 135 in the post-intervention group. No significant demographic or clinical differences existed between groups. Median morphine milliequivalents (MMEs) prescribed were significantly reduced from 225 (225-310) to 75 (75-113) in the post-intervention group (p < 0.0001). Median MMEs consumed were significantly reduced from 109 (111-207) to 15 (0-75), p < 0.0001), as well. Refill request rates remained equivalent during the study (Pre: 17% v Post: 13%, p = 0.9) while patient awareness of safe disposal increased (Pre: 25% v Post: 62%, p < 0.0001)., Discussion: An opioid reduction toolkit significantly reduced the number of postoperative opioids prescribed and consumed after open pancreatectomy, while refill request rates remained the same and patients' awareness of safe disposal increased., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Major airway surgery can pose a complex problem to perioperative central airway management. Adjuncts to advanced ventilation strategies have included cardiopulmonary bypass, veno-arterial, or veno-venous extracorporeal life support. We performed a systematic review to assess the existing evidence utilizing these strategies., Methods: An electronic search was conducted to identify studies written in English reporting the use of extracorporeal life support (ECLS) during central airway surgery. Thirty-six articles consisting of 78 patients were selected and patient-level data were analyzed., Results: Median patient age was 47 [IQR: 34-53] and 59.0% (46/78) were male. Indications for surgery included central airway or mediastinal cancer in 57.7% (45/78), lesion or injury in 15.4% (12/78), and stenosis in 12.8% (10/78). Support was initiated pre-operatively in 9.9% (7/71) and at the time of induction in 55.3% (42/76). It was most commonly used at the time of tracheal resection/repair [93.2% (68/73)], intubation of the tracheal stump [94.4% (68/72)], and re-anastomosis [94.2% (65/69)]; 13.7% (10/73) patients were supported post-operatively. The most commonly performed surgery was tracheal repair or resection in 70.3% (52/74). Median hospital stay was 12 [8, 25] days and in-hospital mortality was 7.9% (6/76). There was no significant difference in survival between the three groups (p = .54)., Conclusions: Extracorporeal membrane oxygenation offers versatility in timing, surgical approach, and ECLS runtime that makes it a viable addition to the surgical armamentarium for treating complex central airway pathologies., (© 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Background: Preventing postoperative 30-day readmissions requires an investment in patient care. The use of postdischarge telehealth visits to prevent potential adverse events or hospital visits has been shown in previous studies., Purpose: We aim to determine the impact of postoperative telehealth visits (PTV) on reducing emergency department visits (EDV) and readmissions within 30 days postdischarge (30DR)., Methods: All elective thoracic surgery patients opted-in or opted-out of PTV. Postoperative telehealth visits assessed patients' overall health status and addressed patient concerns. Patients were also seen at their postoperative clinic follow-up. Emergency department visits and 30DR were recorded., Results: Three hundred fourty-one patients were included-295 and 46 patients opted-in and opted-out of PTV. Opting-out of PTV, being discharged with chest tubes or drains, and the inability to perform activities of daily living at their postoperative follow-up were associated with increased EDV (OR = 8.7, 5.3, 6.3; p ≤ .05) and 30DR (OR = 5.1, 6.3, 7.1; p ≤ .05)., Conclusion: Postoperative telehealth visits were able to reduce EDV and 30DR in our study, although further studies establishing the range of interventions that can be feasibly provided remotely should be performed to identify limitations of these PTV., Implications: Telehealth could be used postoperatively to reduce EDV and 30DR, improving quality and cost-effectiveness of healthcare delivery to patients., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 National Association for Healthcare Quality.)

Background: Treatment guidelines for stage I-III esophageal cancer indicate that management should include surgery in appropriate patients. Variations in utilization of surgery may contribute to racial differences observed in survival. We sought to identify factors associated with racial disparities in surgical resection of esophageal cancer and evaluate associated survival differences., Methods: Patients diagnosed with stage I-III esophageal cancer from 2004 to 2015 were identified using the National Cancer Database. Matched patient cohorts were created to reduce confounding. Multivariate logistic regression was used to identify factors associated with receipt of surgery. Multi-level modeling was performed to control for random effects of individual hospitals on surgical utilization., Results: A total of 60,041 patients were included (4402 black; 55,639 white). After 1:1 matching, there were 5858 patients evenly distributed across race. For all stages, significantly fewer black than white patients received surgery. Black race independently conferred lower likelihood of receiving surgery in single-level multivariable analysis (OR (95% CI); stage I, 0.67 (0.48-0.94); stage II, 0.76 (0.60-0.96); stage III, 0.62 (0.50-0.76)) and after controlling for hospital random effects. Hospital-level random effects accounted for one third of the unexplained variance in receipt of surgery. Risk-adjusted 1-, 3-, and 5-year mortality was higher for patients who did not undergo surgery., Conclusion: Black patients with esophageal cancer are at higher risk of mortality compared to white patients. This increased risk may be influenced by decreased likelihood of receiving surgical intervention for resectable disease, in part because of between-hospital differences. Improving access to surgical care may improve disparities in esophageal cancer survival.

Background Commonly used cardiovascular risk calculators do not provide risk estimation of stroke, a major postoperative complication with high morbidity and mortality. We developed and validated an accurate cardiovascular risk prediction tool for stroke, major cardiac complications (myocardial infarction or cardiac arrest), and mortality after non-cardiac surgery. Methods and Results This retrospective cohort study included 1 165 750 surgical patients over a 4-year period (2007-2010) from the American College of Surgeons National Surgical Quality Improvement Program Database. A predictive model was developed with the following preoperative conditions: age, history of coronary artery disease, history of stroke, emergency surgery, preoperative serum sodium (≤130 mEq/L, >146 mEq/L), creatinine >1.8 mg/dL, hematocrit ≤27%, American Society of Anesthesiologists physical status class, and type of surgery. The model was trained using American College of Surgeons National Surgical Quality Improvement Program data from 2007 to 2009 (n=809 880) and tested using data from 2010 (n=355 870). Risk models were developed using multivariate logistic regression. The outcomes were postoperative 30-day stroke, major cardiovascular events (myocardial infarction, cardiac arrest, or stroke), and 30-day mortality. Major cardiac complications occurred in 0.66% (n=5332) of patients (myocardial infarction, 0.28%; cardiac arrest, 0.41%), postoperative stroke in 0.25% (n=2005); 30-day mortality was 1.66% (n=13 484). The risk prediction model had high predictive accuracy with area under the receiver operating characteristic curve for stroke (training cohort=0.869, validation cohort=0.876), major cardiovascular events (training cohort=0.871, validation cohort=0.868), and 30-day mortality (training cohort=0.922, validation cohort=0.925). Surgery types, history of stroke, and coronary artery disease are significant risk factors for stroke and major cardiac complications. Conclusions Postoperative stroke, major cardiac complications, and 30-day mortality can be predicted with high accuracy using this web-based predictive model.

Background: AKI after surgery is associated with high mortality and morbidity. The purpose of this study is to develop and validate a risk prediction tool for the occurrence of postoperative AKI requiring RRT (AKI-dialysis)., Methods: This retrospective cohort study had 2,299,502 surgical patients over 2015-2017 from the American College of Surgeons National Surgical Quality Improvement Program Database (ACS NSQIP). Eleven predictors were selected for the predictive model: age, history of congestive heart failure, diabetes, ascites, emergency surgery, hypertension requiring medication, preoperative serum creatinine, hematocrit, sodium, preoperative sepsis, and surgery type. The predictive model was trained using 2015-2016 data ( n =1,487,724) and further tested using 2017 data ( n =811,778). A risk model was developed using multivariable logistic regression., Results: AKI-dialysis occurred in 0.3% ( n =6853) of patients. The unadjusted 30-day postoperative mortality rate associated with AKI-dialysis was 37.5%. The AKI risk prediction model had high area under the receiver operating characteristic curve (AUC; training cohort: 0.89, test cohort: 0.90) for postoperative AKI-dialysis., Conclusions: This model provides a clinically useful bedside predictive tool for postoperative AKI requiring dialysis., Competing Interests: All authors have nothing to disclose., (Copyright © 2021 by the American Society of Nephrology.)

Purpose: Our institution's hepatopancreaticobiliary surgery service (HPBS) has demonstrated low rates of venous thromboembolism (VTE). We sought to determine whether the HPBS's regimented multimodal VTE prophylaxis pathway, which includes the use of mechanical prophylaxis, pharmacological prophylaxis, and ambulation, plays a role in achieving low VTE rates. Methods: We compared pancreatic surgeries in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) participant user file with our institution's data from 2011 to 2016 using univariate, multivariate, and matching statistics. Results: Among 36,435 NSQIP operations, 850 (2.3%) underwent surgery by the HPBS. The HPBS achieved lower VTE rates than the national cohort (2.0% vs. 3.5%, p  = 0.018). Upon multivariate analysis, having an operation performed by the HPBS independently conferred lower odds of VTE incidence in the matched cohort (odds ratio = 0.530, p  = 0.041). Conclusions: We identified an independent correlation between the HPBS and decreased VTE incidence, which we believe to be due to strict adherence to and team participation in a high risk VTE prophylaxis pathway, including inpatient pharmacological prophylaxis, thromboembolic deterrent stockings, sequential compression devices, and mandatory ambulation., Competing Interests: No competing financial interests exist., (© Samantha L. Savitch et al. 2020; Published by Mary Ann Liebert, Inc.)

Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.

Hospital-acquired venous thromboembolism (VTE) affects morbidity and mortality and increases health care costs. Poor adherence to recommended prophylaxis may be a potential cause of ongoing events. This study aims to identify institutional adherence rates and barriers to optimal VTE prophylaxis. The authors performed patient and nurse interviews and a concurrent review of clinical documentation, utilizing a cloud-based, HIPAA-compliant tool, on a convenience sample of hospitalized patients. Adherence and agreement between different assessment modalities were calculated. Seventy-six patients consented for participation. Nurse documented adherence was 66% (29/44), 44% (27/61), and 89% (50/56) for mechanical, ambulatory, and chemoprophylactic prophylaxis, respectively. Patient report and nurse documentation showed moderate agreement for mechanical and no agreement for ambulatory adherence (κ = 0.51 and 0.07, respectively). Concurrent review using a cloud-based tool can provide robust, timely, and relevant information on adherence to recommended VTE prophylaxis. Iterative concurrent reviews can guide efforts to improve adherence and reduce rates of hospital-acquired VTE.

Objective: Enhanced recovery pathways reduce length of stay and costs following lung resection. However, many fear that early discharge may lead to increased hospital readmissions. In this study, we aimed to determine whether early discharge was associated with increased readmission following anatomic lung resection., Methods: Using the lung resection database approved by our institutional review board, we identified all patients undergoing minimally invasive lobectomy and segmentectomy between January 2010 and March 2017 at our institution, where an enhanced recovery pathway is well established. Thirty-day readmissions were compared between patients with short- and average length of stay, defined as 1 to 2 days and 3 to 5 days, respectively. Multivariable logistic regression analysis of patients matched by propensity scores was performed to determine odds of 30-day readmission for each group. Significance was set at P < 0.05., Results: A total of 296 patients met inclusion criteria. Unadjusted analysis revealed a 3-fold increased rate of readmission in the group with average length of stay (9%, n = 12) versus the group with short length of stay (3%, n = 5; P < 0.01). At baseline, patients with average length of stay had increased rates of preoperative chemotherapy (13%, n = 18 vs. 4%, n = 6; P < 0.01) and radiation (12%, n = 16 vs. 3%, n = 5). Patients with average length of stay also had higher rates of lobectomy (95%, n = 127 vs. 86%, n = 140; P = 0.02) and postoperative complications (31%, n = 41 vs. 4%, n = 7; P < 0.01). On multivariable analysis, patients with average length of stay had a 2.3-fold greater odds of readmission, which was not statistically significant (OR = 2.33; 95% CI, 0.60 to 9.02; P = 0.22)., Conclusions: Early discharge following minimally invasive anatomic lung resection does not increase the risk of hospital readmission in patients treated within an enhanced recovery pathway.

Purpose: In a previous study of smoking cessation in veterans with lung cancer, we noted as an incidental finding that current smokers were much younger than former smokers at diagnosis. To confirm and extend this observation, we analyzed the association of smoking status with age at diagnosis and survival of lung cancer patients., Methods: The Jefferson Cancer Registry collects information on all cancer patients registered at this hospital. Information on smoking status has been recorded since 1995. We determined age at diagnosis and survival of current and former smokers with lung cancer., Results: 5111 lung cancer cases were identified in the registry from 1995 to 2011 inclusive. Smoking status was recorded in 4687 cases (91.7%). Of these, 1859 (39.7%) were current, 2423 (51.7%) were former, and 405 (8.6%) were never smokers. There was a 6-year difference in median age at lung cancer diagnosis between the current (63 years) and former smokers (69 years) (P < 0.0001). The median survival was 12.1 months for current versus 14.5 months for former smokers (P < 0.0001)., Conclusions: These results confirm and extend our observation that among patients diagnosed with lung cancer, current smokers are younger than former smokers. The possible explanations include higher competing causes of death and increased risk of lung cancer among current smokers as well as increasing proportions of former smokers in older populations. Ongoing exposure to tobacco carcinogens may accelerate the development of lung cancer in continuing smokers. This provides more incentive for smokers to quit at the earliest age possible.

A historical vignette regarding Dr. Algernon Brashear Jackson, the first Black male graduate from Jefferson Medical College. It details his early life, medical school years, surgical training, and contributions to his local community and beyond as he paved the way for future doctors of color.

This historical vignette describes the professional career of Gerald J. Marks, the founder of the Society of American Gastrointestinal and Endoscopic Surgeons and the International Federation of Societies of Endoscopic Surgeons. Dr. Marks is also the founding Associate Editor of Surgical Endoscopy, which celebrated its 30th anniversary in 2017. Dr. Marks is a renowned colorectal surgeon, an accomplished watercolor artist, and a fascinating personality.

Background: Treatment of congenital pulmonary airway malformations (CPAMs) is generally surgical resection; however, there is controversy regarding the optimal timing of surgical intervention, especially in asymptomatic patients., Study Design: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who underwent lung resection for CPAMs were identified. Outcomes in children who underwent lung resection during the neonatal period were compared with those who underwent resection beyond the neonatal period, but during the first year of life (non-neonates)., Results: A total of 541 patients (20.7% neonates and 79.3% non-neonates) were identified. Neonates had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with non-neonates (morbidity 19.6% vs 5.4%, p < 0.0001). On multivariable regression analysis, the presence of preoperative symptoms (defined as oxygen dependence or ventilatory support) was independently associated with increased morbidity (odds ratio 3.91 [range 1.6 to 9.57], p = 0.003). In a subgroup analysis of asymptomatic neonates compared with asymptomatic non-neonates, there was no difference in overall morbidity (7.4% vs 4.4%, p = 0.33)., Conclusions: These data suggest that lung resection for CPAMs in the neonatal period in asymptomatic children are not associated with increased 30-day morbidity. The presence of preoperative symptoms was independently associated with increased morbidity in a multivariable regression model. More data are needed to better understand the long-term outcomes and better define the optimal timing of surgery in this patient population., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

René Gerónimo Favaloro prided himself on being a "simple country doctor." Born in La Plata, Argentina, Dr. Favaloro had an interest in Argentina's sociopolitical and healthcare systems beginning at a young age. He began his medical education at La Universidad Nacional de La Plata, graduating in 1949 with plans to continue his medical education in the field of surgery; however, in 1950, Dr. Favaloro temporarily resigned from his position as a surgeon to work as a country doctor in a small province of La Pampa, Argentina. It was during this time that Dr. Favaloro became acutely aware of the overwhelmingly poor state of the healthcare system in Argentina. In 1962, Dr. Favaloro redirected his focus back to his surgical interests and moved to the United States to work at the Cleveland Clinic, where he discovered the use of the saphenous vein graft for revascularization of the coronary arteries. Despite a productive medical career in the United States, Dr. Favaloro eventually brought his work back to Argentina, where his heart had always remained. Throughout the incredible milestones of his life, Dr. René Gerónimo Favaloro consistently remained a humble, gracious, and simple country doctor.

Objective: This study aims to develop a Respiratory Failure Risk Score (RFRS) with good predictability for elective abdominal and vascular patients to be used in the outpatient setting for risk stratification and to guide preoperative pulmonary optimization., Summary Background Data: Postoperative respiratory failure (RF), defined as ventilator dependency for more than 48 hours or unplanned reintubation within 30 days, is associated with increased mortality and hospital costs. Many tools have been previously described for risk stratification, but few target elective surgical candidates., Methods: Our training sample included patients undergoing inpatient, nonemergent general and vascular procedures sampled for the American College of Surgeon National Surgical Quality Improvement Program 2012 Participant Use File. Multivariable logistic regression identified independent preoperative risk factors associated with RF, used to derive a weighted RFRS. We then determined goodness-of-fit and optimal cutoff values through receiver operator characteristic analysis and Youden indices to evaluate internal and external validity with a retrospective institutional validation sample (2013 and 2014)., Results: Multivariable analysis of 151,700 patients from the National Surgical Quality Improvement Program Participant Use File identified 12 variables independently associated with RF. The RFRS showed good external prediction in the validation sample with a c-statistic of 0.73 (95% confidence interval, 0.68-0.79). With the highest Youden index, 30 was determined to be the optimal cutoff value with a sensitivity 0.62 and specificity of 0.75. Additional cutoff values of 15 and 40 optimized sensitivity (>0.80) and specificity (>0.80), respectively., Conclusions: In the preoperative setting, the RFRS can effectively stratify patients into low (<15), moderate low (15-29), moderate high (30-39), and high risk (>39) to assist in patient counseling and guide application of perioperative pulmonary optimization measures.

World War I (WWI) and World War II (WWII) both presented physicians with challenges unseen before in history. New inventions such as the machine gun and poisonous gas in WWI and the massive aircraft battles in WWII required physicians and surgeons to adapt and innovate to provide the best care and preventative measures for service members. One physician, Malcolm Cummings Grow, distinguished himself as an innovator, a researcher, and a leader. His contributions to the field of military medicine, flight surgery, and medical administration led to countless lives being saved during the two World Wars and laid the groundwork for many different combat protective equipment still in use today.

Purpose: Many studies recently focus on complicated and expensive genomic tests, but the prognostic values of biochemical markers which are easily obtained in clinics are largely overlooked and without further exploration. This study assesses the association of neutrophil-lymphocyte-ratio (NLR) with prognosis of lung cancer patients., Methods: In 1032 patients with histologically confirmed lung cancer, the association of pretreatment NLR values with overall survival (OS) was evaluated using a Cox proportional hazards model and the temporal relationship of longitudinal NLR was assessed using a mixed effects model., Results: Compared to the patients with a low pretreatment NLR value, those with elevated NLR exhibited a statistically significant worse OS with a hazard ratio (HR) of 1.50 (P < 0.0001) after adjusting for age, gender, race, smoking status, drinking status, tumor stage, tumor grade, histology, and treatments. A significant trend of increasing HRs along with increasing NLR values was observed. The increased risk of death conferred by pretreatment NLR values reached a peak level around 2 years after diagnosis. Moreover, in longitudinal analysis, we observed a trend of dramatically increased NLR values in patients who died during follow-up, but stable NLR values in those who were still alive, with a significant interaction of death-alive status with follow-up time (P < 0.0001)., Conclusions: Elevated NLR is a potential biomarker to identify lung cancer patients with poor prognosis and should be validated in a future clinical trial.

William Arbuthnot Lane contributed to the advancement of many fields of orthopedics, otolaryngology, and general surgery. He is credited for his "no-touch technique" and the invention of long-handled instruments, some of which are still in use today, to minimize tissue handling. He is most well known for his hypothesis that slowing of gastric contents could cause a variety of ailments and this became known as Lane's disease. Although his surgical treatment of Lane's disease is now defunct, it advanced the surgical technique in colorectal surgery. It seems likely that some of Lane's "autointoxication" patients would be classified today as patients with colonic inertia, diverticulitis, colonic volvulus, and megacolon or, which are all treated with colectomy. Lane was a pioneer in multiple fields and a true general surgeon. He advanced colorectal surgery immensely and propelled the field of surgery into a new era.

Background: Surgical site infections (SSIs) cause significant patient morbidity and increase costs. This work prospectively examines our institutional effort to reduce SSIs through a resident-driven quality initiative., Methods: A general surgery resident-championed, evidenced-based care bundle for patients undergoing colorectal surgery at a single academic institution was developed using attending mentorship. National Surgical Quality Improvement Program definitions for SSIs were used. Data were collected prospectively and bundle compliance was monitored using a checklist. The primary outcome compared SSIs before and after implementation., Results: In the 2 years preceding standardization, 489 colorectal surgery cases were performed. SSIs occurred in 68 patients (13.9% SSI rate). Following implementation of the bundle, 212 cases were performed with 10 SSIs (4.7% SSI rate, P < .01). Multivariate logistic regression analysis found a decrease in superficial and overall SSIs (odds ratio .17, 95% confidence interval .05 to .59; odds ratio .31, 95% confidence interval .14 to .68)., Conclusions: These data demonstrate that resident-driven initiatives to improve quality of care can be a swift and effective way to enact change. We observed significantly decreased SSIs with a renewed focus on evidence-based, standardized patient care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The life and work of Dr. Lyon Henry Appleby, M.D., portrays the essence of a devoted clinician committed to scholarly excellence. Born in Deseronto, Ontario, in 1895 and passing in 1970, Dr. Appleby influenced all areas of general surgery, most notably popularizing a procedure that bears his name today. After a tour in World War I, he quickly proved himself to be a dedicated clinician with roots in academia, which translated into excellence within the Department of Surgery at St. Paul's Hospital in Vancouver, Canada. He served in various leadership roles including Chair of the Department of Surgery, President of the International College of Surgeons, and Fellow of the Royal College of Physicians and Surgeons. The Appleby procedure, or en bloc removal of the celiac axis, at the time of gastrectomy, is the technical focus of this paper, although reference is made to Appleby's extensive contributions to historical medicine.

Background:: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously., Methods:: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade., Results:: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO., Conclusions:: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery.

A 22-year-old Asian male presented with fever, non-productive cough, right-sided pleuritic chest pain and was found to have a large right hydropneumothorax. A chest tube was placed. Pleural fluid analysis revealed a lymphocytic predominant exudate and he was subsequently started on four-drug daily anti-tuberculosis therapy (isoniazid, ethambutol, rifampin, pyrazinamide). Pleural biopsy revealed acid-fast bacilli. Given his persistent pleural effusion, he was given four doses of intrapleural tissue plasminogen activator (tPA) and dornase alpha (DNase) via his chest tube over a period of 6 days resulting in clinical and radiologic improvement. Pleural biopsy and pleural fluid culture specimens later revealed Mycobacterium tuberculosis. Intrapleural tPA-DNase therapy has demonstrated improved resolution of infections and shortened hospitalizations for parapneumonic infectious effusions. However, there is little literature on the use of intrapleural fibrinolytics specifically for pleural tuberculosis associated effusions. Furthermore, the American Thoracic Society does not comment on therapeutic thoracentesis or intrapleural fibrinolytic therapy in their recommendations for treatment of pleural tuberculosis. In our case of pleural TB-associated hydropneumothorax, the use of intrapleural tPA-DNase therapy facilitated pleural fluid drainage and resulted in near-complete resolution of the effusion.

Edward William Alton Ochsner kept a plain, metal card file in which he recorded close to 50 years worth of medical experiences, research, and insights. The most populated topics were filed as "Cancer, Lung" and "Cancer, Bronchogenic." These reflected his areas of greatest interest, for which he would go on to produce groundbreaking work. Of his many lifetime accomplishments, he is perhaps best known for being the first to report a link between cigarette smoking and lung cancer. This was just one of the many ways in which Ochsner worked to effect social change. The establishment of the Ochsner Health System in New Orleans was born from this similar passion. Ochsner went on to become one of the giants of his generation as a result of this tireless work as a leader, educator, and mentor.

Background: Using data from the Nationwide Inpatient Sample, we investigated the impact of surgical approach and race on in-hospital mortality after lobectomy for lung cancer., Methods: Logistic regression was used to model odds ratios for in-hospital mortality related to surgical technique (thoracotomy vs video assisted thoracoscopic surgery [VATS]) and race using discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality (2008 to 2011)., Results: VATS lobectomies increased each year (25.9% to 39.2%, P = .001) in the 19,353 patients identified. A racial disparity was noted, with black patients being 66% more likely to die in the hospital (odds ratio 1.66, 95% confidence interval 1.17 to 2.37, P = .005). Excluding 2010 data suggests that there is evidence of benefit associated with VATS; however, no evidence of an association between race and in-hospital mortality exists., Conclusions: This study elucidates race-related mortality in lobectomy patients. Although racial disparities are present throughout health care, this finding emphasizes one of the challenges in using large databases to assess such disparities., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Francis Daniels Moore was a pioneer ahead of his time who made numerous landmark contributions to the field of surgery, including the understanding of metabolic physiology during surgery, liver and kidney transplant, and the famous Study on Surgical Services of the United States (SOSSUS) report of 1975 that served for decades as a guideline for development of surgical residencies. He was the epitome of what a physician should be, a compassionate and dedicated surgeon, innovative scientist, and a medical professional dedicated to quality medical education across all specialties.