Faculty Bibliography

BACKGROUND:: A recently available, low profile, fully covered metal stent with symmetrical flares (FCMSF) may offer improved resistance to migration in esophageal disease. MATERIALS AND METHODS:: A retrospective review of 58 esophageal FCMSF placed in 46 consecutive patients was performed. Pathologies included stricture and leak of benign and malignant etiology. RESULTS:: Sixteen of 58 stents (28%) were placed urgently/emergently. All patients had successful stent deployment with 0% stent-related hospital mortality. Postoperative morbidity occurred in 15 of the 58 (26%) stents and included stent migration, atrial fibrillation, pneumonia, pneumothorax, urinary retention, hemodynamic instability, and chronic obstructive pulmonary disease exacerbation. In patients with stricture (n=29), mean dysphagia scores were reduced from 3.1+/-0.6 preoperatively to 1.1+/-0.8 postoperatively (P<0.001). For leak, stent therapy (+/-drainage) avoided formal esophageal operation in 95% (21/22). Four stents (6.9%) were removed for stent migration, 2 of which migrated after adjuvant chemoradiation. Adjuvant chemoradiation therapy was an independent risk factor for stent migration (odds ratio=1.6; P=0.02) by multivariable regression analysis. The mean duration of stent therapy was 65+/-62 days for stricture (27/34 remain in situ) and 57+/-57 days for leak (10/22 remain in situ). The median hospital length of stay was 2 days. CONCLUSIONS:: FCMSF provide a safe and effective therapy for both benign and malignant esophageal dysphagia and leaks. The symmetrical property may contribute to the overall low observed migration rate while still allowing for simple and safe stent retrieval.

Background: Covered stents have become part of the armamentarium for treating various esophageal pathologies. A recently available, low profile, fully covered metal stent with symmetrical flares (FCMSF) may offer improved deployment and resistance to migration. Methods: A retrospective review of 58 esophageal FCMSF placed in 47 consecutive patients by a single thoracic surgeon between March 2010 and February 2012 was performed. Pathologies included benign and malignant stricture and leak. Stents were placed endoscopically under general anesthesia using a 6 mm deployment system; bidirectional maneuverability was possible. Dysphagia score (0-4) was prospectively recorded. Leak treatment was assessed with postoperative esophagrams. Results: Mean age was 62.0 years. Sixteen of 58 stents (28%) were placed urgently/emergently. All patients had successful stent deployment with 0% stent-related hospital morbidity/mortality. Overall post-operative morbidity occurred following 12/58 stents, including arrhythmia, pneumonia, pneumothorax, urinary retention, hemodynamic instability, and COPD exacerbation. In patients with stricture (n = 29), mean dysphagia scores were reduced from 3.0 preoperatively to 1.2 post-operatively (p < 0.001). for leak, stent therapy (+/- drainage) avoided formal esophageal operation in 94% (17/18). Fifteen stents were removed during follow-up, 4 after migration. Mean overall survival was 2.3 +/- 2.6 months for stricture (21/35 remain alive) and 8.7 +/- 9.6 months for leak (16/18 remain alive). Mean duration of stent therapy was 4.9 +/- 4.8 months for stricture (29/35 remain in situ) and 3.5 +/- 3.2 months for leak (10/20 remain in situ). Mean hospital stay was 3.9 +/- 7.0 days. Discussion: FCMSF are an effective therapy for both esophageal strictures and leaks. The symmetrical covered flares likely contribute to the low observed migration rate

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway obstruction is an extremely rare event found almost exclusively in the intensive care unit. We describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope, without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway bleeding after bronchial disimpaction to separate from CPB

OBJECTIVE: Current video-assisted thoracoscopic surgery training models rely on animals or mannequins to teach procedural skills. These approaches lack inherent teaching/testing capability and are limited by cost, anatomic variations, and single use. In response, we hypothesized that video-assisted thoracoscopic surgery right upper lobe resection could be simulated in a virtual reality environment with commercial software. METHODS: An anatomy explorer (Maya [Autodesk Inc, San Rafael, Calif] models of the chest and hilar structures) and simulation engine were adapted. Design goals included freedom of port placement, incorporation of well-known anatomic variants, teaching and testing modes, haptic feedback for the dissection, ability to perform the anatomic divisions, and a portable platform. RESULTS: Preexisting commercial models did not provide sufficient surgical detail, and extensive modeling modifications were required. Video-assisted thoracoscopic surgery right upper lobe resection simulation is initiated with a random vein and artery variation. The trainee proceeds in a teaching or testing mode. A knowledge database currently includes 13 anatomic identifications and 20 high-yield lung cancer learning points. The 'patient' is presented in the left lateral decubitus position. After initial camera port placement, the endoscopic view is displayed and the thoracoscope is manipulated via the haptic device. The thoracoscope port can be relocated; additional ports are placed using an external 'operating room' view. Unrestricted endoscopic exploration of the thorax is allowed. An endo-dissector tool allows for hilar dissection, and a virtual stapling device divides structures. The trainee's performance is reported. CONCLUSIONS: A virtual reality cognitive task simulation can overcome the deficiencies of existing training models. Performance scoring is being validated as we assess this simulator for cognitive and technical surgical education