Introduction Current Advanced Trauma Life Support guidelines recommend decompression for thoracic tension physiology using a 5-cm angiocatheter at the second intercostal space (ICS) on the midclavicular line (MCL). High failure rates occur. Through systematic review and meta-analysis, we aimed to determine the chest wall thickness (CWT) of the 2nd ICS-MCL, the 4th/5th ICS at the anterior axillary line (AAL), the 4th/5th ICS mid axillary line (MAL) and needle thoracostomy failure rates using the currently recommended 5-cm angiocatheter. Methods A comprehensive search of several databases from their inception to July 24, 2014 was conducted. The search was limited to the English language, and all study populations were included. Studies were appraised by two independent reviewers according to a priori defined PRISMA inclusion and exclusion criteria. Continuous outcomes (CWT) were evaluated using weighted mean difference and binary outcomes (failure with 5-cm needle) were assessed using incidence rate. Outcomes were pooled using the random-effects model. Results The search resulted in 34,652 studies of which 15 were included for CWT analysis, 13 for NT effectiveness. Mean CWT was 42.79 mm (95% CI, 38.78–46.81) at 2nd ICS-MCL, 39.85 mm (95% CI, 28.70–51.00) at MAL, and 34.33 mm (95% CI, 28.20–40.47) at AAL (P=0.08). Mean failure rate was 38% (95% CI, 24–54) at 2nd ICS-MCL, 31% (95% CI, 10–64) at MAL, and 13% (95% CI, 8–22) at AAL (P=0.01). Conclusion Evidence from observational studies suggests that the 4th/5th ICS-AAL has the lowest predicted failure rate of needle decompression in multiple populations.

Thirty patients with chemotherapy-naïve advanced non-small-cell lung cancer (NSCLC) were given escalating doses of paclitaxel (150, 175, 200 mg/m2) on day 1 in three consecutive cycles, together with a fixed dose of gemcitabine 1000 mg/m2 on days 1 and 8; cycles were repeated every three weeks. The dose escalation of paclitaxel was feasible in the majority of patients. Subsequently, 30 other NSCLC patients received a dose of 200 mg/m2 paclitaxel with gemcitabine 1000 mg/m2 in a phase II study. The major side effect was mild myelosuppression. A response rate of 24% was achieved in 49 fully evaluable patients. This regimen proved to be safe and easy to administer on an out-patient setting, and constitutes now one of the arms of the current EORTC randomized study for advanced NSCLC.

No abstract

Introduction Tube thoracostomy (TT), considered a routine procedure, has significant complications. Current recommendations for placement rely on surface anatomy. There is no information to guide operators regarding angle of insertion relative to chest wall. We aim to determine if angle of insertion is associated with complications of TT. Methods We performed a retrospective review of adult trauma patients who necessitated TT at a level I trauma center over a 2 year period (January 2012 – December 2013). TT performed intraoperatively or using radiological guidance were excluded. Thoracic anteroposterior (AP) or posteroanterior (PA) radiographs were reviewed to determine the angle of insertion of TT relative to the thoracic wall. A previously validated classification method was utilized to categorize complications. Descriptive and univariate statistics were used to compare angle of insertion and complicated vs uncomplicated TT. Results Review identified 154 patients who underwent a total of 246 TT placed for emergent trauma. All patients had a post-procedural chest x-ray. We identified 90 complications (37%) over the study period. 144 of the TT’s reviewed had an angle of insertion less than 45 degrees of which there were 27 complications (19%). 102 of the TT’s had an angle greater than 45 degrees and 63 complications (62%), P<0.0001. Conclusions Tube thoracostomy insertion is inherently dangerous. Placement of TT using a higher angle of insertion greater than 45 degrees is associated with increased complications. Further prospective studies quantifying TT angle of insertion on outcomes are needed. Level of Evidence Level IV therapeutic study.

Laparoscopic Nissen fundoplication for large paraesophageal hernias was associated with an increased incidence of leak and reoperation when compared with Belsey fundoplication. Belsey Mark IV fundoplication should be considered when deciding on what operation to perform in patients with large paraesophageal hernias.

Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.

No abstract

Background Decompression of tension physiology may be lifesaving, but significant doubts remain regarding ideal needle thoracostomy (NT) catheter length in treatment of tension physiology. We aim to demonstrate increased clinical effectiveness of longer NT angiocatheter length (8cm) compared to current Advanced Trauma Life Support (ATLS) recommendations of 5cm NT length. Methods A retrospective review of all adult trauma patients from 2003–2013 (age >15 years old) transported to a level I trauma center. Patients underwent NT at the 2nd intercostal space, midclavicular line (2nd ICS-MCL), either at the scene of injury, during transport (prehospital) or during initial hospital trauma resuscitation. Before March 2011, both prehospital and hospital trauma team NT equipment routinely had a 5 cm angiocatheter available. After March 2011 prehospital providers were provided an 8 cm angiocatheter. Effectiveness was defined as documented clinical improvement in respiratory, cardiovascular, or general clinical condition. Results There were 91 NT performed on 70 patients (21 bilateral placements) either in the field (prehospital, n=41) or as part of resuscitation in the hospital (hospital, n=29). Effectiveness of NT was 48% until March 2011 (n=24). NT effectiveness was significantly higher in the prehospital setting than hospital (68.3% success rate versus 20.7%, p<0.01). Patients who underwent NT using 8 cm compared to 5 cm were significantly more effective (83% VS 41% respectively, p=0.01). No complications of NT were identified in either group. Conclusion 8 cm angiocatheters are more effective at chest decompression compared to currently recommended 5 cm at the 2nd ICS-MCL Level of Evidence III Retrospective comparative study without negative criteria.