Richard P Koehler’s research while affiliated with Virginia Mason Medical Center and other places

National and subspecialty guidelines for lung and esophageal cancers recommend treatment decisions to be made in a multidisciplinary tumor board (MTB). This study prospectively analyzes the actual impact of presentation at the thoracic tumor board on decision making in thoracic cancer cases. During the electronic submission process for presentation at MTB managing physicians documented their current treatment plan. The initial treatment plan was compared with the MTB final recommendation. Patient demographics, physician's proposed treatment plan, MTB recommendation, and documentation of application of MTB recommendations were prospectively recorded in an Institutional Review Board approved database. Between June 2010 and December 2012, 185 patients with esophageal and 294 patients with lung cancer were presented at the MTB. One hundred sixty-six patients were presented on more than 1 occasion, resulting in 724 assessments of 479 patients. In 48 esophageal cancer patients (26%) and 118 lung cancer patients (40%) MTB recommendations differed from the initial treatment plan. Overall, a differing MTB recommendation from the primary treatment plan occurred in 330 of 724 case presentations (46%). The MTB recommendations changed treatment plans in 40% and staging and assessment plans in 60% of patients. Follow-up in a cohort of 249 patients confirmed that MTB recommendations were followed in 97% of cases. This study validates the impact of the thoracic MTB. Recommendations will differ from the managing providers' initial plan in 26% to 40% of cases. However, MTB recommendations can be successfully initiated in the majority of patients. Complex thoracic cancer patients will benefit from multidisciplinary review and should ideally be presented at tumor board. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Background: A significant percentage of patients with paraesophageal hernia (PEH) will have a co-existing diagnosis of iron-deficiency anemia which will resolve following surgical repair. Methods: Between 2000 and 2010, 270 patients underwent operative repair of PEH. Of this group, 123 patients (45.6 %) reported a preexisting diagnosis of iron-deficiency anemia. The study group consisted of 77 patients with a documented preoperative hemoglobin level (Hb) consistent with iron-deficiency anemia and a follow-up level at least 3 months following surgery. Results: Of the 77 patients included, 72 underwent elective repair, median age was 75 (39-91) years, and 65 % were female. Cameron erosions were identified preoperatively in 32 %. Mean preoperative hemoglobin was 9.6 (4.4-13.6) g/dl and postoperative hemoglobin was 13.2 (10.7-17) g/dl at 3-12 months and 13.6 (9.7-17.2) g/dl at more than 1 year. Ninety percent of patients had a rise in postoperative hemoglobin level by at least 1 g/dL. Anemia resolved in 55 (71 %) patients, more often in women and younger patients (<70 years). Twenty-nine of 40 (73 %) patients on iron therapy discontinued this postoperatively. Conclusion: A significant number of patients who present with giant PEH will present with iron-deficiency anemia. Elective repair will result in resolution of the anemia in more than 70 % of patients. PEH is underappreciated as a source of iron-deficiency anemia, and appropriate patients should be considered for elective repair.

Esophageal fistula following esophagectomy is associated with significant morbidity and mortality. We present the case of a 71-year-old man who underwent salvage Ivor-Lewis esophagectomy, following definitive chemoradiotherapy 1 year previously. On postoperative day 9 the patient complained of chest pain, and a CT scan demonstrated extravasation of oral contrast from the gastric conduit into the right chest. A right chest drain and fully covered esophageal stent were placed at this time. Despite these measures, after 8 weeks, the esophageal fistula persisted. Ultimately, fistula closure was achieved using an interventional radiology-guided, endoscopically placed over-the-scope clip (OTSC). The patient had no further complications and was well at 3 months follow-up. The case reported herein describes this novel, combined-modality approach to esophageal fistula closure. This case report demonstrates a novel, minimally invasive, multidisciplinary approach to the closure of a post-esophagectomy anastamotic leak.

We propose that the symptoms associated with paraesophageal hernia (PEH) are more diverse than previously suggested, and symptoms and clinical manifestations correlate to the anatomy of the hernia. Patients undergoing surgery for PEH were reviewed from a prospective, institutional review board-approved, single-center database. Presenting symptoms, anatomy of the PEH, demographics, and outcomes were analyzed from 2000 to 2010. Presenting symptoms were assessed for incidence and improvement after surgery. Size and configuration of the PEH were assessed with respect to presenting symptoms. The study included 270 consecutive patients, 63% were female, and the median age was 70 years (range, 39 to 94 years). The most common presenting symptoms were heartburn in 175 patients (65%), early satiety in 136 patients (50%), chest pain in 130 patients (48%), dyspnea in 130 patients (48%), dysphagia in 129 patients (48%), regurgitation in 128 patients (47%), and anemia in 112 patients (41%). Two hundred sixty-nine patients (99.6%) had at least one symptom; the median number of symptoms was 4 (range, 0 to 10). The type of PEH was II (n=10), III (n=206), and IV (n=54), and the percent intrathoracic stomach was less than 50% (n=33), 50% to 74% (n=86), 75% to 99% (n=55), and 100% (n=96). Paraesophageal hernia type was significantly associated with heartburn (type II/III; p=0.005) and dyspnea (type IV; p=0.007). Significant associations included lower percent intrathoracic stomach with regurgitation (p=0.04); higher percent intrathoracic stomach with early satiety (p=0.02), decreased meal size (p=0.007), and dyspnea (p<0.001); and 50% to 74% intrathoracic stomach with anemia (p=0.001). With a median postoperative follow-up of 103 days, symptoms were subjectively better in patients with dyspnea (67%), early satiety (79%), regurgitation (92%), dysphagia (81%), chest pain (76%), and heartburn (93%). Paraesophageal hernia is associated with a greater diversity of symptomatic presentation than previously thought. Asymptomatic patients are rare, and size and configuration of the hernia are associated with specific symptoms. Patients with large PEHs should be assessed by an experienced surgeon for elective repair.

Assessment of the clinical impact of giant paraesophageal hernias have historically focused on upper gastrointestinal symptoms. This study assesses the effect of paraesophageal hernia repair on respiratory function. All patients undergoing repair of giant paraesophageal hernia were prospectively entered into a database approved by the institutional review board. Patients had symptoms documented preoperatively, including dyspnea. Pulmonary function tests (PFTs) were done preoperatively and repeated a median of 106 days after repair (range, 16-660 days). Preoperative and postoperative PFTs were obtained in 120 unselected patients treated for paraesophageal hernia between 2000 and 2010. Patients' median age was 74 years (range, 45-91 years), 74 (62%) were female, and median body mass index was 28.0 (range, 16.8-46.6). Median length of stay was 4 days (range, 3-10 days), and perioperative mortality was zero. Hernias were classified as type II in 3 (3%) patients, III in 92 (77%), and IV in 25 (21%). Percent of intrathoracic stomach was assigned from preoperative contrast studies and grouped as less than 50% (n = 6; 5%), 50% to 74% (n = 35; 29%), 75% to 99% (n = 29; 24%), and 100% (n = 50; 42%). Preoperative symptoms included heartburn 71 (59%), early satiety 65 (54%), dyspnea 63 (52%), chest pain 48 (40%), dysphagia 56 (47%), regurgitation 47 (39%), and anemia 44 (37%). PFTs significantly improved after paraesophageal hernia repair (mean volume change, percent reference change): forced vital capacity +0.30 L,+10.3%pred; FEV(1) +0.23 L,+10.4%pred (all P < .001); diffusion capacity of the lung for carbon monoxide +0.58 mL · mm Hg(-1) · min(-1) (P = .004), and +2.9%pred (P = .002). Greater improvements were documented in older patients with significant subjective respiratory symptoms and higher percent of intrathoracic stomach (P < .01). Paraesophageal hernia has a significant effect on respiratory function, which is largely underappreciated. This study demonstrates that these repairs can be done safely and supports routine consideration for elective repair; older patients with borderline respiratory function may achieve substantial improvements in their respiratory status and quality of life.

Management of acute esophageal perforation continues to evolve. We hypothesized that treatment of these patients at a tertiary referral center is more important than beginning treatment within 24 hours, and that the evolving application of nonsurgical treatment techniques by surgeons would produce improved outcomes. Demographics and outcomes of patients treated for esophageal perforation from 1989 to 2009 were recorded in an Institutional Review Board-approved database. Retrospective outcomes assessment was done for 5 separate time spans, including timing and type of treatment, length of stay (LOS), complications, and mortality. Eighty-one consecutive patients presented with acute esophageal perforation. Their mean age was 64 years, and 55 patients (68%) had American Society of Anesthesiologists levels 3 to 5; 59% of the study population was referred from other hospitals; 48 patients (59%) were managed operatively, 33 (41%) nonoperatively, and 10 patients with hybrid approaches involving a combination of surgical and interventional techniques; 57 patients (70%) were treated <24 hours and 24 (30%) received treatment >24 hours after perforation. LOS was lower in the early-treatment group; however, there was no difference in complications or mortality. Nonoperative therapy increased from 0% to 75% over time. Nonsurgical therapy was more common in referred cases (48% vs 30%) and in the >24 hours treatment group (46% vs 38%). Over the period of study, there were decreases in complications (50% to 33%) and LOS (18.5 to 8.5 days). Mortality for the entire series involved 3 patients (4%): 2 operative and 1 nonoperative. Results from our series indicate that referral to a tertiary care center is as important as treatment within 24 hours. An experienced surgical management team using a diversified approach, including selective application of nonoperative techniques, can expect to shorten LOS and limit complications and mortality.

Report our implementation of a standardized handover process in a general surgery residency program. The standardized handover process, sign-out template, method of implementation, and continuous quality improvement process were designed by general surgery residents with support of faculty and senior hospital administration using standard work principles and business models of the Virginia Mason Production System and the Toyota Production System. Nonprofit, tertiary referral teaching hospital. General surgery residents, residency faculty, patient care providers, and hospital administration. After instruction in quality improvement initiatives, a team of general surgery residents designed a sign-out process using an electronic template and standard procedures. The initial implementation phase resulted in 73% compliance. Using resident-driven continuous quality improvement processes, real-time feedback enabled residents to modify and improve this process, eventually attaining 100% compliance and acceptance by residents. The creation of a standardized template and protocol for patient handovers might eliminate communication failures. Encouraging residents to participate in this process can establish the groundwork for successful implementation of a standardized handover process. Integrating a continuous quality-improvement process into such an initiative can promote active participation of busy general surgery residents and lead to successful implementation of standard procedures.

Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100-400 ml) for the TH group and 216 ml (range 80-500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥ 10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p=0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p=0.01. This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.