Preoperative Chest X-ray Research Articles

Cardiopulmonary Testing before Pediatric Adenotonsillectomy for Severe and Very Severe Obstructive Sleep Apnea Syndrome.

Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely. Retrospective chart review. We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest X-rays (CXRs). Mean age was 5.9 (±3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (±23.8) and 80.7% (±9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4). Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost. 4 Laryngoscope, 131:2361-2368, 2021.

Value of Perioperative Chest X-ray for the Prediction of Sternal Wound Complications after Cardiac Surgery in High-Risk Patients: A "Work in Progress" Analysis.

Background. Sternal wound complications are serious events that occur after cardiac surgery. Few studies have investigated the predictive value of chest X-ray radiological measurements for sternal complications. Methods. Several perioperative radiological measurements at chest X-ray and clinical characteristics were computed in 849 patients deemed at high risk for sternal dehiscence (SD) or More than Grade 1 Surgical Site Infection (MG1-SSI). Multivariable analysis identified independent predictors, whilst receiver operating characteristics (ROC) curve analyses highlighted cut-off values of radiological measurements for the prediction of both complications. Results. SD occurred in 8.8% of the patients, MG1-SSI in 6.8%. Chronic obstructive pulmonary disease (COPD) was the only independent predictor for SD (Odds Ratio, O.R. 12.1; p < 0.001); proximal sternal height (PSH) was the only independent protective factor (O.R. 0.58; p < 0.001), with a cut-off value of 11.7 mm (sensitivity 70.5%, specificity 71.0%; ROC area under the curve (AUC) = 0.768, p < 0.001). Diabetes mellitus (O.R. 3.5; p < 0.001) and COPD (O.R. 21.3; p < 0.001) were independent predictors for MG1-SSI; indexed proximal sternal height (iPSH) was as a protective factor (O.R. 0.26; p < 0.001) with a cut-off of 5.97 mm (sensitivity 70.2%, specificity 69.0%; ROC AUC = 0.739, p < 0.001). No other radiological measurements were independently correlated with SD or MG1-SS (p = N.S.). Conclusion. PSH and iPSH at preoperative chest X-ray may act as indicators of high risk for sternal wound complications, allowing for early preventative measures.

Selective approach to preoperative echocardiography in esophageal atresia.

Preoperative echocardiography is used routinely in neonates with esophageal atresia to identify patients in whom congenital cardiac disease will impact upon anesthetic and surgical decision-making. We aimed to determine the suitability of selective preoperative echocardiography. We performed a single-center retrospective review of neonates with esophageal atresia over 6 years (2010-2015) at our tertiary pediatric institution. Data included preoperative clinical examination, chest x-ray, and echocardiography. Endpoints were cardiovascular, respiratory, radiological, and echocardiography findings. Selective strategies were assessed using sensitivity, specificity, positive predictive value, and negative predictive value. We identified 115 neonates with esophageal atresia. All underwent preoperative echocardiography. Cardiac defects were identified in 49/115 (43%) (major 9/115, moderate 4/115). Sensitivity, specificity, positive predictive value, and negative predictive value of abnormal clinical and radiologic assessment for major and moderate cardiac defects were 92%, 25%, 13%, 96%; for clinical examination alone were 92%, 25%, 14%, 96%; for absence of murmur, cyanosis, and abnormal respiratory examination were 92%, 28%, 13%, 97%. Selective strategies reduce echocardiograms performed by 22%. Selective strategies allow for identification of neonates with esophageal atresia who may have deferral of echocardiogram unill after surgery. Selection may improve timeliness of care and resource utilization, without compromising patient safety.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

Background: Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice. Methods: This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to “Choosing Wisely”, “No Hacer” and “Essencial” initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units. Results: A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the “No Hacer” recommendation and 73.3% according to “Choosing Wisely” and “Essencial” criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to “Choosing Wisely” and “Essencial”; 4.1% according to “No Hacer”). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to “No Hacer” and EUR 3895.29 (2276.1 Relative Value Units) according to “Choosing Wisely” or “Essencial” criteria. Conclusions: There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Factors influencing preoperative chest radiography request for elective endoscopic procedures among medical personnel.

Chest radiography is not routinely recommended before elective endoscopies. A high incidence of perioperative chest radiography requests was observed at our institution. This study aims to investigate factors influencing preoperative chest radiography request for patients undergoing elective gastrointestinal (GI) endoscopies. This cross-sectional clinical study recruited 264 participants from different medical specialties who were responsible for preoperative endoscopic chest x-ray (CXR) ordering including anesthesiologists, surgeons and gastroenterologists. They completed questionnaires exploring their general knowledge and attitudes about preoperative chest radiography. Demographic characteristic of the participants affecting the knowledge on preoperative chest radiography was determined. A Structural Equation Model (SEM) was constructed from validated conceptual framework to find causal relationships between hypothesized factors and intention for preoperative endoscopic chest radiography request. Statistical analyses were performed using the SPSS software version 18.0 and Analysis of Moment Structures (AMOS) version 18.0. The questionnaire response rate was 53.79%. Baseline general knowledge on preoperative chest radiography of the participants was comparable. The SEM results showed unsupported relationship between hypothesized factors and the intention for preprocedural GI endoscopic CXR request (p < 0.1). General knowledge of medical personnel on tuberculosis needs improvement. To rectify the unnecessary chest radiography request before elective GI endoscopic procedures, awareness of the patients' health conditions, adherence to the hospital's policy and realizing of possible patient-related mishaps are not the determinants for preprocedural endoscopic chest radiography request. Future works are required to explore other alternative factors involved for reducing chest radiography requests which are not indicated.

Impact of right ventricular systolic pressure in elderly patients admitted to intensive care unit after femur fracture surgery: A retrospective observational study.

The number of femoral fractures is expected to continue to increase as the size of the older population rapidly grows. However, old age is accompanied by various comorbidities and is an important postoperative risk factor in itself, meaning that patients who undergo surgery for a femur fracture may require admission to an ICU. We investigated pulmonary complications in patients over the age of 65 admitted to the ICU after femur fracture surgery.In this single-center retrospective observational study, 289 patients over 65 years who admitted to the ICU after femur fracture surgery between June 2008 and December 2016 were investigated.Pulmonary complications occurred in 97 of these patients (33.6%) after surgery. Mean hospitalization days (34.1 ± 25.7 vs 23.1 ± 15.7, P < .001) and mean ICU length of stay (8.4 ± 16.1 vs 2.5 ± 1.1, P = .001) were significantly longer for patients with pulmonary complications than for patients without pulmonary complications after femur fracture surgery. Patients with pulmonary complications were significantly more likely to have pulmonary disease (19.6% vs 8.9%, P = .009) and exhibit sequelae on preoperative chest X-rays (9.3% vs 3.6%, P = .048) than were patients without pulmonary complications. In addition, significant differences were observed in the right ventricular systolic pressure (RVSP) measured during preoperative echocardiography (37.4 ± 10.9 mm Hg vs 40.7 ± 9.3 mm Hg for patients without and with pulmonary complications, P = .010) and in the proportion of each group that had an RVSP of >35 mm Hg, which is a marker for pulmonary hypertension (55.2% vs 76.3% for patients without and with pulmonary complications, P < .001). In multivariate analysis, an RVSP of >35 mm Hg during preoperative echocardiography was associated with pulmonary complications after femur fracture surgery (OR, 2.6; 95% CI, 1.45-4.53).In conclusion, Pulmonary complications in older patients admitted to the ICU after femur fracture surgery was associated with longer hospitalization and ICU stays. Preoperative RVSP measurement could identify those older patients with a high risk of pulmonary complications following transferal to the ICU after femur fracture surgery.

Detection of Second Primary Lung Cancers on Surveillance Imaging Following SABR for Early Stage NSCLC

Second primary lung cancers (SPLC) are common following initial treatment of lung cancer. Detection of SPLC following surgical lung cancer management is well-described in the literature. However, development of SPLC and relationship to surveillance imaging following stereotactic ablative radiation therapy (SABR) is less established. The purpose of this study was to report incidence of and outcomes for SPLC detected in a cohort of patients treated with SABR for early stage NSCLC and followed by frequent surveillance chest CT. We hypothesize that with regular surveillance, most SPLC will be detected at an early stage and treated with curative intent. Following IRB approval, all patients treated with SABR for early stage NSCLC at our institution between 02/2007-05/2019 were retrospectively identified and reviewed. Patient and treatment characteristics, frequency and duration of surveillance chest CT, and development of SPLC were recorded. Positron emission tomographic staging was performed for all patients with new SPN to assess for nodal or distant disease. Surveillance CT was performed Q3 month year one, Q3-6 month year 2, Q6-12 month year 3-5, and Q12 month thereafter. Actuarial estimates of development of SPLC and overall survival (OS) were generated using the Kaplan Meier method. We identified 175 patients treated with SABR for early stage NSCLC, and 136 had ≥6 months follow up and were eligible. The median age was 75.1 years (range: 61.7-92.1), and smoking history was 36.5 pack-year (PY) (range: 0-160 PY). Patients were treated to 50-60 Gy over 3-8 fractions. Three-year OS for the cohort was 75%. Eighteen patients (13.2%) developed SPLC at a median of 23.3 months (range 3.0-84.7 months) following SABR, 18 (90%) of which were biopsy proven. Nineteen (95%) of SPLC were detected on routine surveillance imaging and one was detected on a pre-operative chest x-ray 82 months post-SABR after discontinuing surveillance. Two (10%) were histologically consistent with small cell carcinoma. Two patients developed 2 metachronous SPLC. The 3 and 5-year estimates of SPLC were 16% and 20%, respectively. Eighteen (90%) SPLC were treated with curative intent with SABR (n = 17) or microwave ablation (n = 1). One SPLC was metastatic at detection. Two and 3-year estimates of OS following detection of SPLC were 73% and 27% respectively. SPLC were significantly more common in the present cohort than other published studies, potentially related to high rates of tobacco use and older age in our cohort. Outcomes following surveillance detected SPLC appear excellent, and most patients in our cohort were treated with curative intent. The high frequency of SPLC in our cohort suggests annual screening beyond five years of disease surveillance is warranted in this population, and that further studies to refine overall surveillance in very high-risk populations are needed.

COVID-19 Early After a Deceased Donor Kidney Transplant Surgery

Many transplant centers reduced their solid organ transplant procedures in response to the coronavirus disease 2019 pandemic.1,2 We describe the course of a kidney transplant recipient who presented with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection 10 days after transplant surgery. The patient is a 41-year-old Hispanic woman with end-stage kidney disease secondary to lupus nephritis on maintenance hydroxychloroquine 200 mg daily who presented for a zero HLA A, B, DR mismatched deceased donor kidney transplant. The donor was involved in a motor vehicle accident and sustained multiple injuries resulting in his death. He had a negative SARS-CoV-2 nasopharyngeal swab. The patient denied symptoms of SARS-CoV-2 infection or exposure to SARS-CoV-2-positive individuals and stayed at home before transplant except for going to her dialysis unit. Her preoperative nasopharyngeal swab for SARS-CoV-2 was negative and her chest X-ray was normal. She received induction immunosuppression with intravenous high-dose steroids and reduced-dose rabbit anti-thymocyte globulin, 3 mg/kg per our center’s protocol for zero antigen-mismatched transplants, and maintenance tacrolimus, mycophenolate 500 mg twice daily and prednisone taper in addition to hydroxychloroquine. She had immediate allograft function and was discharged 5 days following her transplant with serum creatinine of 1.7 mg/dL. Her absolute lymphocyte count at the time of discharge was 550 cells/mm3. Ten days posttransplant, she developed a fever of 100°F, dry cough, sore throat, and 2 episodes of diarrhea. A nasopharyngeal swab was obtained and was positive for SARS-CoV-2. It is thought that she acquired SARS-CoV-2 infection from contact with a family member who worked in a grocery store. Her oxygen saturation was 97% on room air and she had normal vital signs. Chest X-ray showed a new discoid opacity within the right lower lung (Figure 1). Mycophenolate was held, prednisone dose was immediately reduced from 20 mg to 10 mg and then to 5 mg maintenance, tacrolimus was dosed to maintain trough levels of 7–10 ng/mL, and hydroxychloroquine was increased to 200 mg twice daily, based on earlier reports in the pandemic about its presumed effectiveness. C-reactive protein was 0.4 mg/dL, absolute lymphocyte count was 1200 cells/mm3, and serum creatinine was 1.1 mg/dL. She received 1 unit of convalescent plasma transfusion through Food and Drug Administration expanded access pathway under a protocol that was approved by our Institutional Review Board; however, after completion, she developed urticaria, which was treated with antihistamines. She had a positive direct antiglobulin test confirming the transfusion reaction. She remained clinically stable and was discharged after 1 day of hospitalization with a pulse oximeter to monitor her oxygen saturation at home. More than 60 days have passed since discharge, and she continues to do well.FIGURE 1.: Left, Preoperative chest X-ray. Right, Chest X-ray at the day of presentation with COVID-19 symptoms.This report demonstrates that despite acquiring SARS-CoV-2 at the “peak” of immunosuppression, which included lymphocyte depletion, our patient had only mild symptoms and did not develop serious complications. The utility of convalescent plasma in renal transplant recipients with SARS-CoV-2 is not well defined. A recent report described successful recovery in a kidney transplant recipient who had severe infection with SARS-CoV-2 and was treated with 2 units of convalescent plasma.3 In view of the very recent and “heavy” immunosuppression in our patient, we decided to utilize convalescent plasma, despite her mild illness. More data are needed to better describe SARS-CoV-2 infection and treatment in peritransplant period. Finally, it is crucial to highlight the importance of taking meticulous measures and precautions in this patient population, especially in the presence of household contacts working at potentially “high risk” jobs for acquiring and transmitting SARS-CoV-2. Self-quarantine, physical distancing, and frequent hand hygiene should be undertaken at the highest potential levels.

Aortic calcifications on routine preoperative chest X-ray and perioperative stroke during cardiac surgery: a nested matched case-control study.

Perioperative stroke in cardiac surgery is most often embolic in origin. Preoperative chest X-ray (CXR) is routinely used amongst others to screen for relevant aortic calcification, a potential source of embolic stroke. We performed a nested matched case-control study to examine the relationship between aortic calcifications on CXR and the occurrence of embolic stroke. Among all consecutive patients undergoing cardiac surgery in our hospital between January 2014 and July 2017, we selected all patients with perioperative embolic stroke (cases). Controls, all patients without perioperative stroke, were matched on age, sex and type of surgery. All preoperative CXRs were scored for aortic calcifications (none, mild, severe) in the ascending aorta, arch, aortic knob and descending aorta. Out of the 3038 eligible patients, 27 cases were detected and 78 controls were selected. In the stroke group, mild-to-severe calcifications were found least often in the ascending aorta [9% of patients, 95% confidence interval (CI) 1-29%] and most frequently in the aortic knob (63% of patients, 95% CI 44-78%). The distribution of aortic calcification was comparable in cases versus controls. Calcification burden was comparable between the cases and their matched controls. In our study population, CXR findings on aortic calcification were not related to the risk of embolic stroke. In these patients, the correlation between findings on the preoperative CXR and the risk of stroke might, therefore, be too weak to use the CXR directly for the assessment of the safety of manipulating the ascending aorta during surgery.

Reducing low value services in surgical inpatients in Taiwan: Does diagnosis-related group payment work?

Reducing low-value care is a top priority in health care. However, how prospective payment methods such as diagnosis-related group (DRG) payment scheme reduce the use of low-value services is unclear. This study aimed to assess frequency of low-value preoperative testing services among surgical inpatients over time and to investigate whether the 2010 Tw-DRG policy has reduced utilization of these services under the National Health Insurance program in Taiwan. The nationwide National Health Insurance claims data in Taiwan from 2008 to 2013 were used. The difference-in-differences (DID) method was adopted. Utilization of three low-value preoperative testing services (chest x-ray, echocardiogram, and stress testing) were assessed. The prevalence of the three preoperative tests ranged from 0.13 per 100 admissions (preoperative stress testing) to 78.12 per 100 admissions (preoperative chest x-ray). Following the implementation of the Tw-DRG policy, the predicted probability of low-value care use was significantly reduced from 67.91% to 64.93% in the DRG group but remained relatively stable in the comparison group (from 69.44% to 68.43%) in 2010. The use of three selected preoperative tests had only a minor temporary reduction in 2010, but later increased over time. The 2010 Tw-DRG policy did not significantly moderate the growth of low-value preoperative use. Hospital financial incentives alone may be insufficient for reducing the provision of low-value care.

Utility of Electrocardiogram and Chest X-Ray for Preoperative Evaluation in Benign Hysterectomy

Abstract Objective: The aims of this research were to evaluate concordance of practice patterns for preoperative electrocardiogram (EKG) and chest X-ray for benign hysterectomy with institutional a...

Evaluation of an Intervention to Reduce Low-Value Preoperative Care for Patients Undergoing Cataract Surgery at a Safety-Net Health System

Preoperative testing for cataract surgery epitomizes low-value care and still occurs frequently, even at one of the nation's largest safety-net health systems. To evaluate a multipronged intervention to reduce low-value preoperative care for patients undergoing cataract surgery and analyze costs from various fiscal perspectives. This study took place at 2 academic safety-net medical centers, Los Angeles County and University of Southern California (LAC-USC) (intervention, n = 469) and Harbor-UCLA (University of California, Los Angeles) (control, n = 585), from April 13, 2015, through April 12, 2016, with 12 additional months (April 13, 2016, through April 13, 2017) to assess sustainability (intervention, n = 1002; control, n = 511). To compare pre- and postintervention vs control group utilization and cost changes, logistic regression assessing time-by-group interactions was used. Using plan-do-study-act cycles, a quality improvement nurse reviewed medical records and engaged the anesthesiology and ophthalmology chiefs with data on overuse; all 3 educated staff and trainees on reducing routine preoperative care. Percentage of patients undergoing cataract surgery with preoperative medical visits, chest x-rays, laboratory tests, and electrocardiograms. Costs were estimated from LAC-USC's financially capitated perspective, and costs were simulated from fee-for-service (FFS) health system and societal perspectives. Of 1054 patients, 546 (51.8%) were female (mean [SD] age, 60.6 [11.1] years). Preoperative visits decreased from 93% to 24% in the intervention group and increased from 89% to 91% in the control group (between-group difference, -71%; 95% CI, -80% to -62%). Chest x-rays decreased from 90% to 24% in the intervention group and increased from 75% to 83% in the control group (between-group difference, -75%; 95% CI, -86% to -65%). Laboratory tests decreased from 92% to 37% in the intervention group and decreased from 98% to 97% in the control group (between-group difference, -56%; 95% CI, -64% to -48%). Electrocardiograms decreased from 95% to 29% in the intervention group and increased from 86% to 94% in the control group (between-group difference, -74%; 95% CI, -83% to -65%). During 12-month follow-up, visits increased in the intervention group to 67%, but chest x-rays (12%), laboratory tests (28%), and electrocardiograms (11%) remained low (P < .001 for all time-group interactions in both periods). At LAC-USC, losses of $42 241 in year 1 were attributable to intervention costs, and 3-year projections estimated $67 241 in savings. In a simulation of a FFS health system at 3 years, $88 151 in losses were estimated, and for societal 3-year perspectives, $217 322 in savings were estimated. This intervention was associated with sustained reductions in low-value preoperative testing among patients undergoing cataract surgery and modest cost savings for the health system. The findings suggest that reducing low-value care may be associated with cost savings for financially capitated health systems and society but also with losses for FFS health systems, highlighting a potential barrier to eliminating low-value care.

What is the Utility of Routine Complete Blood Count, Liver Function Tests, and Chest X-ray in the Evaluation of Patients with Clinically Node-Negative Breast Cancer?

National Comprehensive Cancer Network guidelines suggest a selective workup of early-stage breast cancer with complete blood count (CBC) and liver function tests (LFTs) and no longer recommend chest X-ray (CXR) to screen for occult metastasis. We evaluated the utility of routine preoperative screening tests in patients with clinically node-negative (cN0) breast cancer. We identified 1611 patients with cN0 breast cancer treated at our institution between October 1998 and December 2015; 94.4 per cent of the patients underwent at least one preoperative screening test: 90.8 per cent CBC, 89.4 per cent LFTs, and 63.6 per cent CXR. Thirty-six per cent of CBCs, 13.1 per cent of LFTs, and 6.7 per cent of CXRs were abnormal. Abnormalities led to 17 CT scans, and one found an occult metastasis. Eleven patients (0.7%) were diagnosed with metastatic disease postoperatively, but only half had abnormal preoperative screening tests. Positive predictive values of preoperative CBC, LFTs, and CXR for occult metastasis are 1.3 per cent, 1.1 per cent, and 1.5 per cent, respectively. Preoperative screening in cN0 breast cancer is of low yield. Even when abnormalities are found, metastasis is present in less than 1 per cent of patients, and a normal study does not rule out metastasis. Routine preoperative determination is not warranted, and staging studies should be limited to patients with signs or symptoms.

Prediction of Gap Length by Plain Radiograph of Chest with Nasogastric Tube in the Upper Esophagus in Patients with Esophageal Atresia and Distal Tracheoesophageal Fistula.

Aim:This study was aimed at prediction of the gap length between the two esophageal ends in cases of esophageal atresia and distal tracheoesophageal fistula (EA-TEF) by preoperative radiography with a nasogastric tube in the upper esophagus and its correlation with intraoperatively measured gap length.Materials and Methods:All consecutive cases of EA-TEF were prospectively included in this study. Plain radiographs were taken with an 8 Fr nasogastric tube inserted in the upper esophageal pouch till its arrest. The patients were grouped into T1-T2; T2-T3; T3-T4; and T4 groups depending on the thoracic vertebral level of arrest of the NG tube on the radiograph. Intraoperative gap between the two esophageal ends was measured with Vernier caliper, and the patients were grouped into A, B, and C groups based on gap length (gap length >2.1 cm; >1–≤2 cm; and ≤1 cm). The operative gap groups were compared with the radiography groups.Results:A total number of 118 cases were included over a period of 3 years. The arrest of nasogastric tube at T1-T2 and T2-T3 vertebral level corresponded to gap length Group A in 39/41 (95.12%) * patients. In gap length Group B, the arrest of tube at T2-T3 and T3-T4 vertebral level was seen in 44/44 (100%)* patients, in gap length Group C, the arrest of tube was noted at T3-T4 and T4 vertebral level in 31/33 (93.93%)* patients (*P < 0.001).Conclusion:Prediction of gap length by vertebral level of arrest of the nasogastric tube in the upper pouch in a preoperative chest X-ray correlated well with intra operatively measured gap length in cases of EA-TEF.

Outcomes of Hip Arthroplasty in Sickle Cell Disease: A 20 Year Retrospective Review

BackgroundAvascular necrosis (AVN) of the hip joints is a common and debilitating complication of sickle cell disease (SCD) of all subtypes. The femoral head of the hip joint is highly susceptible to injury from decreased blood flow. In sickle cell disease, the polymerization of deoxygenated Hemoglobin S leads to decreased deformability and vaso-occlusion in the vascular beds of the bone marrow and periosteum. In some patients, this pathological process is severe, leading to osteonecrosis and collapse of the femoral head and requiring surgical intervention in the form of total hip arthroplasty. Untreated, AVN can lead to the development of chronic pain and frequent hospitalizations. Historically, outcomes for hip arthroplasty have been poor. Furthermore, AVN has been shown to be positively associated with frequency of pain crisis contributing to the economic burden of sickle cell anemia complications on the health care system. One national database estimated post-operative complications during knee or hip replacement among sickle cell anemia patients was 152% higher with up to 42% longer duration of hospitalization when compared to those without sickle cell disease.MethodsSince 1995, the New York Presbyterian Brooklyn Methodist Hospital center, a community hospital in Brooklyn, New York, has developed a comprehensive health maintenance program for patients with SCD. This program was developed with the goal of providing a central institution to manage the complexities of the sickle cell patient population. Our comprehensive care includes provision of genetic counselling, health maintenance services, screening for complications of sickle cell disease, social work and health education services. We conducted a retrospective descriptive analysis of adult patients with sickle cell anemia who underwent hip arthroplasty between 1996 to 2016. We reviewed lab data, length of hospital stay for hip surgery, use of transfusions and post-operative complications.ResultsOf the 505 adult patients in our database, there were 21 total hip arthroplasties performed on 17 patients - 47% Hemoglobin (Hb) SS, 29% Hb SC, and 24% Hb S/Beta0 thalassemia. The median age at surgery was 41 years (range 22 to 78 years); 65% were female. Baseline hemoglobin in non-SS patients was 10.2 g/dL and in SS patients was 8.5 g/dL. All patients had pre-operative chest X-ray, pulmonary function tests and Echocardiograms. Preoperative transfusion was utilized in 67% of cases. The average length of hospital stay was 8.7 days. There were no episodes of acute chest syndrome after surgery, but 2 patients were re-admitted within 30 days- one with pulmonary embolism and one with abdominal sepsis unrelated to surgery. Two patients suffered venous thromboembolism post-operatively, which was the most common complication in the sample. Two patients were on hydroxyurea at time of surgery- both could not be transfused peri-operatively because of history of delayed transfusion reactions due to red cell alloimmunization. Both patients had hospital stays less than the average stay. All patients received intensive physical therapy and were given incentive spirometers following procedures with frequent follow up in the clinic.ConclusionsThese data demonstrate that through a multi-disciplinary approach to care, perioperative complications following hip arthroplasty occurred less frequently when compared to previous data. Although protocols were in place for post-operative venous thromboembolism prophylaxis, this was the most common complication seen in our study. Given the complexities of Sickle cell disease and the increasing cost associated with this procedure, a comprehensive multi-disciplinary approach to care is the key to positive outcomes in these patients. DisclosuresNo relevant conflicts of interest to declare.

Utility of Electrocardiogram and Chest X-Ray for Preoperative Evaluation in Benign Hysterectomy

Objective: No single standard of care exists for the use of electrocardiogram (EKG) and chest x-ray (CXR) in gynecologic surgery. We aimed to assess first, concordance between our local practice pattern and Institutional versus National Institute for Health and Care Excellence (NICE) guidelines and second, the utility of preoperative EKG and CXR for benign hysterectomy.

Accuracy of chest X-Ray measurements of pediatric esophageal coins

ObjectiveTo determine the accuracy of chest x-ray measurements in children using ingested radiopaque foreign bodies of known size. MethodsA database of foreign body ingestions at a tertiary care children's hospital was queried from 2013 to 2016 for children who had ingested a US coin, had a pre-operative chest x-ray and documentation of coin type at the time of endoscopic removal. Four blinded research subjects measured the coin diameter on chest x-ray using iSite PACS software and based on the measurement, predicted the coin type. Measurements were compared to the known coin diameters published by the US Mint. ResultsA total of 51 patients with sixteen esophageal quarters (diameter 24.26 mm), fourteen nickels (21.21 mm), fourteen pennies (19.05 mm) and seven dimes (17.91 mm) were included in the study. The four subjects had a mean accuracy of 60.3% (range 49.0%–72.5%) in predicting the correct coin type. Across all raters, there was poor agreement for pennies (kappa = 0.161) and dimes (kappa = 0.131), fair agreement for nickels (kappa = 0.259), good agreement for quarters (kappa = 0.687), and fair agreement overall (kappa = 0.371). The study measurements overestimated the coin size in 203 of the 204 measurements by a mean of 1.84 mm (range −0.31–3.85 mm). The mean size discrepancy was larger (2.40 vs. 1.30 mm, p < 0.001) and accuracy of coin type identification was worse (44.6% vs. 74.1%, p = 0.001) in children <4 years old. ConclusionsMeasurement of esophageal coins on chest x-ray is relatively inaccurate and overestimates the size in the majority of cases. Clinicians should use caution when performing fine measurements on chest x-rays, especially in children younger than 4 years old.

Cost-effectiveness of preoperative chest X-rays in low-grade endometrial cancer and atypical endometrial hyperplasia

Objective: To determine the cost-effectiveness of obtaining routine preoperative chest X-rays in women with atypical endometrial hyperplasia or low-grade endometrial cancer.

Right Pulmonary Artery Aneurysm Mimicking Tumor on Chest X-Ray in Patient with Eisenmenger Syndrome

A 66-year-old patient with previously diagnosed largeventricular septal defect and Eisenmenger syndrome (ES) performed a preoperative(planned inguinal hernioplasty) chest x-ray that showed a tumor-like lung mass, which led to a chestCT scan. The ChestCT scan showed an extremely dilated right pulmonary artery which mimicked tumor with rarely described atherosclerotic changes in the right blood flow with calcified plaques and thrombotic masses. Since pulmonary artery thrombosis is common in adults with ES, it is our belief that anticoagulation should be considered in this group of patients.

Missed thyroid gland after total thyroidectomy.

Missed gland is an extremely rare condition. It is a mediastinal thyroid mass found after total thyroidectomy. We report a case of missed gland. The patient underwent total thyroidectomy due to multinodular goiter and thyroid stimulating hormone levels did not increase after surgery. Pathological tests revealed a micropapillary carcinoma. Thyroid ultrasonography and scintigraphy scan revealed mediastinal thyroid mass. The patient underwent redo surgery without sternotomy and there was no morbidity after the second surgical procedure. Most missed thyroid gland cases are due to incomplete removal of plunging thyroid goiter during total thyroidectomy. They also can be attributed to a concomitant, unrecognized mediastinal goiter, which is not connected to the thyroid gland with vessels or a thin fibrous band. It should be noted that absence of signs like mediastinal mass or tracheal deviation in preoperative chest X-ray does not exclude substernal goiter. The presence of a missed thyroid gland should be kept in mind when postoperative thyroid stimulating hormone levels remain unchanged.