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Browsing by Author "Rieger, Karen M."
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Item Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies(Elsevier, 2017-09) Ceppa, DuyKhanh P.; Rosati, Carlo Maria; Chabtini, Lola; Stokes, Samantha M.; Cook, Holly C.; Rieger, Karen M.; Birdas, Thomas J.; Lappas, John C.; Kessler, William R.; DeWitt, John M.; Maglinte, Dean D.; Kesler, Kenneth A.; Surgery, School of MedicineBackground Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. Methods After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. Results Eighty patients were referred and transported an average distance of 56 miles (range, 1–163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave’s syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). Conclusions Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.Item Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery(Thieme, 2018-09) Chilukuri, Prianka; Gromski, Mark A.; Johnson, Cynthia S.; Ceppa, Duy Khanh P.; Kesler, Kenneth A.; Birdas, Thomas J.; Rieger, Karen M.; Fatima, Hala; Kessler, William R.; Rex, Douglas K.; Al-Haddad, Mohammad; DeWitt, John M.; Medicine, School of MedicineBackground and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.Item The Influence of Airway Closure Technique for Right Pneumonectomy on Wall Tension During Positive Pressure Ventilation: An Experimental Study(Elsevier, 2020-12) Matthews, Caleb R.; Goswami, Debkalpa; Ramchandani, Neal K.; Huffard, Adrian L.; Rieger, Karen M.; Young, Jerry V.; Martinez, Ramses V.; Kesler, Kenneth A.; Surgery, School of MedicineBronchopleural fistula (BPF) remains a significant source of morbidity and mortality after right pneumonectomy (RPN). Postoperative mechanical ventilation represents a primary risk factor for BPF. We undertook an experiment to determine the influence of airway diameter on suture line tension during mechanical ventilation after RPN. RPN was performed in 6 fresh human adult cadavers. After initial standard bronchial stump closure (BSC), the airway suture lines were subjected to 5 cm H2O incremental increases in airway pressures beginning at 5–40 cm H2O. To minimize airway diameter, a carinal resection was then performed with trachea to left main bronchial anastomosis and the airway suture lines subjected to similar incremental airway pressures. Wall tension (N/m) at the suture lines was measured using piezoresistive sensors at each pressure point. As delivered airway pressure increased, there was a concomitant increase in wall tension after BSC and carinal resection. At every point of incremental positive pressure, wall tension was however significantly lower after carinal resection when compared to BSC (P < 0.05). Additionally the differences in airway tension became even more significant with higher delivered airway pressure (P < 0.001). Airway diverticulum after BSC leads to significantly increased tension on the bronchial closure with positive airway pressure as compared to a closure which minimize airway diameter after RPN. This supports the role of Laplacian Law where small increases in airway diameter result in significant increases on closure site tension. Techniques which reduce airway diameter at the airway closure will more reliably reduce the incidence of BPF following RPN.Item Management of anastomotic leaks following esophagectomy: when to intervene?(AME Publishing Company, 2019-01) Manghelli, Joshua L.; Ceppa, DuyKhanh P.; Greenberg, Jason W.; Blitzer, David; Hicks, Adam; Rieger, Karen M.; Birdas, Thomas J.; Department of Surgery, Indiana University School of MedicineBackground: Esophagectomy is the mainstay treatment for early stage and locoregionally advanced esophageal cancer. Anastomotic leaks following esophagectomy are associated with numerous detrimental sequelae. The management of anastomotic leaks has evolved over time. The present study is a single-institution experience of esophageal leak management over an 11-year period, in order to identify when these can be managed nonoperatively. Methods: All patients undergoing esophagectomy with gastric reconstruction at our institution between 2004 and 2014 were identified. Preoperative patient characteristics and perioperative factors were reviewed. Failure of initial leak treatment was defined as need for escalation of therapy. Length of stay (LOS) and postoperative mortality were the primary outcomes. Follow-up was obtained through institutional medical records and the Social Security Death Index. Results: Sixty-one of 692 (8.8%) patients developed an anastomotic leak. Forty-six patients (75.4%) first underwent observation, which was successful in 35 patients. Predictors of successful observation included higher preoperative albumin (P=0.02), leak diagnosed by esophagram (P=0.004), and contained leaks (P=0.01). Successful observation was associated with shorter LOS (P=0.001). Predictors of mortality included lower preoperative serum albumin (P=0.01) and induction therapy (P=0.03). Thirty and 90-day mortality among patients who developed an anastomotic leak were 9.8% and 16.7%, respectively. Conclusions: Over half of anastomotic leaks were managed successfully with observation alone and did not require additional interventions. We have identified factors that may predict successful therapy with observation in these patients. Further research is warranted to determine more timely interventions for patients likely to fail conservative management.Item Substernal reconstruction following esophagectomy: operation of last resort?(AME Publishing Company, 2017-12) Moremen, Jacob R.; Ceppa, DuyKhanh P.; Rieger, Karen M.; Birdas, Thomas J.; Surgery, School of MedicineBackground: The posterior mediastinum is the preferred location for reconstruction following esophagectomy. Occasionally alternative routes are required. We examined patient outcomes of esophageal reconstruction in order to determine whether substernal reconstruction (SR) is an equivalent alternative to orthotopic placement. Methods: Following IRB approval, we performed a retrospective review of all patients who underwent an esophagectomy from 1988-2014. Only patients reconstructed with a gastric conduit and cervical anastomosis by either substernal or posterior mediastinal (PM) routes were included in the study. Endpoints assessed included anastomotic leak rate, post-operative complications, reoperation, hospital length of stay, and 30- and 90-day mortality. Results: Thirty-three patients underwent SR and 182 had a PM gastric conduit with cervical anastomosis. The SR pathology was predominantly benign while PM was mostly malignant. Sixteen SR patients had a delayed reconstruction after prior diversion. Mean hospital LOS was longer in the SR group (P<0.001). There was no significant difference in 30- and 90-day mortality. PM patients had significantly fewer respiratory complications (P<0.04), reoperations (P<0.04), and transfusions (P<0.0001) and a trend towards fewer anastomotic leaks (17.1% vs. 30.3%; P<0.09). Conclusions: This single institution experience demonstrated no significant difference in mortality between substernal and PM reconstruction following esophagectomy. However, SR was associated with significantly increased LOS and morbidity, including a trend toward increased anastomotic leaks. SR reconstruction should probably be considered an option of last resort.