Objectives The purpose of this study was to compare the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP) at our institution, with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Background Outcomes of ATAAD repair may be improved when operations are performed at specialized high-volume thoracic aortic surgical centers. Methods Between 1999 and 2011, 128 patients underwent ATAAD repair at our institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection pre-operative prediction model. Results Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio 1.30; p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared with the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio 0.15; p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared with 55% for pre-TASP patients (p = 0.002). Conclusions ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team. Efforts to standardize or centralize care of patients undergoing ATAAD are warranted.

Introduction This study compared survival after initial treatment with esophagectomy as primary therapy to induction therapy followed by esophagectomy for patients with clinical T2N0 (cT2N0) esophageal cancer in the National Cancer Database (NCDB). Methods Predictors of therapy selection for patients with cT2N0 esophageal cancer in the NCDB from 1998–2011 were identified with multivariable logistic regression. Survival was evaluated using Kaplan-Meier and Cox proportional-hazards methods. Results Surgery was used in 42.9% (2057/4799) of cT2N0 patients. Of 1599 esophagectomy patients for whom treatment timing was recorded, induction therapy was used in 44.1% (688). Pre-treatment staging was proven accurate in only 26.7% of patients (210/786) who underwent initial surgery without induction treatment and had complete pathologic data available: 41.6% (n=327) were upstaged and 31.7% (n=249) were downstaged. Adjuvant therapy (chemotherapy or radiation therapy) was given to 50.2% of patients treated initially with surgery who were found after resection to have nodal disease. There was no significant difference in long-term survival between strategies of primary surgery and induction therapy followed by surgery (median 41.1 versus 41.9 months, p=.51). In multivariable analysis, induction therapy was not independently associated with risk of death (HR 1.16, p=.32). Conclusions Current clinical staging for early-stage esophageal cancer is highly inaccurate, with only a quarter of surgically resected cT2N0 patients found to have had accurate pre-treatment staging. Induction therapy for patients with cT2N0 esophageal cancer in the NCDB is not associated with improved survival.

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This study confirms the excellent short-term outcomes of TEVAR for acute complicated type B dissection and demonstrates the results to be durable and sustained over long-term follow-up. Although aortic reinterventions were required in one-quarter of patients, no aortic-related deaths were observed. These data support the use of TEVAR for acute complicated type B aortic dissection but also highlight the importance of life-long aortic surveillance by an experienced aortic referral center in order to identify and treat complications of the underlying disease process and treatment, as well as new aortic pathologies, as they arise.

In a comparative effectiveness study of cerebral protection strategies for aortic arch repair, strategies without adjunctive CP, including the most commonly utilized strategy of straight D/P hypothermia, appeared inferior to those utilizing CP. There was no clearly superior strategy among remaining techniques, and randomized trials are needed to define best practice.

Objectives Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery. Methods A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age > 70 years, body mass index < 18.5 kg/m2, anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥ 2. Risk models for length of stay > 14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling. Results Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥ 2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥ 2 was associated with discharge to other than home and 30-day and 1-year mortality. Conclusions Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement.

Background Extracorporeal membrane oxygenation (ECMO) is being increasingly used as a bridge to lung transplantation. Small, single-institution series have described increased success using ECMO in spontaneously breathing patients compared with patients on ECMO with mechanical ventilation, but this strategy has not been evaluated on a large scale. Methods Using the United Network for Organ Sharing database, all adult patients undergoing isolated lung transplantation from May 2005 through September 2013 were identified. Patients were categorized by their type of pretransplant support: no support, ECMO only, invasive mechanical ventilation (iMV) only, and ECMO + iMV. Kaplan-Meier survival analysis with log-rank testing was performed to compare survival based on type of preoperative support. A Cox regression model was used to determine whether type of preoperative support was independently associated with survival, using previously established predictors of survival as covariates. Results Approximately 12,403 primary adult pulmonary transplantations were included in this analysis. Sixty-five patients (0.52%) were on ECMO only, 612 (4.93%) required only iMV, 119 (0.96%) were on ECMO + iMV, and the remaining 11,607 (94.6%) required no invasive support before transplantation. One-year survival was decreased in all patients requiring support, regardless of type. However, mid-term survival was similar between patients on ECMO alone and those not on support but significantly worse with patients requiring iMV only or ECMO + iMV. In multivariable analysis, ECMO + iMV and iMV alone were independently associated with decreased survival compared with nonsupport patients, whereas ECMO alone was not significant. Conclusions In patients with worsening pulmonary disease awaiting lung transplantation, those supported via ECMO with spontaneous breathing demonstrated improved survival compared with other bridging strategies.

Background Controversy exists over whether resection of the primary tumor in stage IV colorectal cancer with inoperable metastases improves patient outcomes. Objective To evaluate whether resection of the primary tumor without metastasectomy in patients with stage IV colorectal cancer is associated with improved overall survival compared to patients undergoing chemotherapy and/or radiation therapy alone. Design The 2003–2006 National Cancer Data Base was reviewed to identify patients with stage IV adenocarcinoma of the colon or rectum who underwent palliative treatment without curative intent, either in the form of surgical resection of the primary tumor without metastasectomy consisting of a colectomy or rectal resection with or without chemotherapy and/or radiation, or chemotherapy and/or radiation alone. Groups were compared for baseline characteristics. Overall survival was compared using Kaplan-Meier analysis before and after propensity matching with a 1:1 nearest neighbor algorithm. Results Of the 1446 patients included in the analysis, 231 (16%) underwent surgical resection of the primary tumor without metastasectomy. Surgical resection was associated with a significant survival benefit upon unadjusted analysis (median survival: 9.2 months vs 7.6 months, p<0.01). After propensity matching to adjust for non-random treatment selection, surgical resection continued to be associated with a significant survival benefit (median survival 9.2 months vs 7.3 months p<0.01). Limitations Potential for selection bias regarding which patients received surgical resection. Lack of data regarding indication for operation, specifically whether a patient was symptomatic or asymptomatic prior to resection. Inability to account for tumor size or grade among patients who did not receive surgical resection. Conclusions Surgical resection of the primary tumor without metastasectomy in patients with metastatic colorectal cancer is associated with improved survival as compared to chemotherapy/radiation therapy alone. Further research is necessary to determine which patients may benefit from this intervention.