The Annals of thoracic surgery
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Multicenter Study
Drivers of 30- and 90-day Postoperative Death After Neoadjuvant Chemoradiation for Esophageal Cancer.
Neoadjuvant chemoradiation, followed by esophagectomy, is a standard of care for locally advanced esophageal cancers. The ChemoRadiOtherapy plus Surgery versus Surgery alone (CROSS) trial reported a 30-day mortality rate of 6%. We sought to evaluate 30- and 90-day mortality in similar patients in the United States and identify predictors of higher mortality rates. ⋯ Postoperative death at 30 and 90 days after neoadjuvant chemoradiation and esophagectomy appears to be on par with randomized data. Positive surgical margins, squamous cell carcinomas, age 69 and older, readmission within 30 days, and conversion from a minimally invasive operation to an open operation all carry a 90-day mortality risk exceeding 10%.
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Data on failure to rescue (FTR) after esophagectomy are sparse. We sought to better understand the patient factors associated with FTR and to assess whether FTR is associated with hospital volume. ⋯ One in 5 esophagectomy patients suffering a complication at low-volume hospitals do not survive to discharge. Several patient factors are associated with death after a major complication. Strategies to improve the recognition and management of complications in at-risk patients may be essential to improve outcomes at low-volume hospitals.
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Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry. ⋯ For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.
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It is controversial if extension of aortic dissection into arch branches should be an indication for replacement of the arch and its branches in acute type A aortic dissection. ⋯ In acute type A aortic dissection, dissection of arch branches alone should not be an indication for routine zone 1/2/3 arch replacement; however zone 1/2/3 arch replacement could be considered to prevent future reoperations in select patients.
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Comparative Study
Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy.
Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. ⋯ These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.