Jenkins, Jan

Importance Pectus arcuatum is a rare anterior chest wall deformity that is often confused with excavatum, carinatum, or a mixed deformity. A complete understanding of its clinical and physiological basis will improve diagnostic accuracy and allow for standardized management. Objectives To gain a comprehensive understanding of pectus arcuatum, focusing on its nomenclatures, epidemiology, classification, pathophysiology, preoperative presentation and assessments, management options, and surgical outcomes. Evidence Review PubMed, Google Scholar, and subsequent reference searches were used to extract original studies addressing pectus arcuatum fully or partially. The searches were performed on February 2, 2025. Two independent reviewers screened articles based on preestablished inclusion and exclusion criteria. Quality assessment was performed, but given the rarity of arcuatum and the limited, heterogeneous nature of available literature, none of the studies were excluded based on the level of evidence or quality assessments. Using a standardized data extraction form, results were synthesized and presented as a review with recommendations to guide clinical decision-making. Findings A total of 65 studies were included in the final review. Of those, 37 (56.9%) were cohort studies, 18 (27.7%) were case reports, 8 (12.3%) were case series, and 2 (3.1%) were technical reports. A total of 455 cases of pectus arcuatum were represented. Heterogeneity was found in nomenclature, epidemiology, associated conditions, assessments, management, and outcomes. An open surgical approach and, more recently, hybrid open and minimally invasive technique are reported for surgical repair. Postoperative outcomes were good in most surgical series, with no significant difference when compared with the repair of other pectus deformities. Conclusions and Relevance Results of this systematic review reveal that pectus arcuatum is a rare variant of pectus deformities that is distinct from carinatum and excavatum. Unified terminology and standardized diagnostic criteria are important to facilitate proper management. Minimally invasive hybrid approaches continue to refine outcomes, balancing invasiveness with efficacy.

Summary Caustic esophageal injury can cause severe morbidity and mortality. Despite the need for emergent treatment, individual experience in diagnosis and management can be limited. Computed tomography (CT) has emerged as a promising non-invasive modality for assessing injury severity, but the clinical utility of both CT and endoscopy should be investigated. A systematic review was conducted following PRISMA guidelines. A comprehensive search of the PubMed database identified relevant articles published from January 1, 2000 to December 31, 2023. Inclusion criteria encompassed studies investigating the use of CT and/or endoscopy in diagnosing and managing caustic esophageal injury. Twelve articles were selected from a pool of 931 studies. Findings suggested that CT was superior in diagnostic capability to endoscopy in high-grade injury and stricture formation, but less so for low grade injuries. Diagnostic algorithms incorporating imaging with laboratory studies have emerged in the literature, which are promising pending additional validation. CT can serve as a valuable, non-invasive tool in the initial evaluation of caustic esophageal injury and is postulated to accurately predict both the need for emergent surgery and the risk of stricture formation. However, CT should not replace but rather complement the use of endoscopy to comprehensively evaluate these potentially highly morbid situations.

Mitral regurgitation (MR) in lung transplant (LTx) recipients is a rare but complex cardiopulmonary phenomenon. The overlap between symptoms of MR and post-LTx complications, such as primary graft dysfunction, complicates its diagnosis and management. This systematic review aims to characterize the incidence, pathophysiology, presentation, and management of MR in LTx patients. We conducted a literature search in PubMed, Web of Science, Scopus, and Embase. The search yielded 133 studies, of which 11 were included. Data regarding MR development, clinical presentation, echocardiographic findings, and management strategies were extracted and analyzed. Perioperative MR, occurring during or immediately post-LTx, was frequently attributed to the systolic anterior motion of the mitral valve (MV) occurring in the setting of hypovolemia and/or inotrope usage. Later postoperative MR, on the other hand, was associated with reverse ventricular remodeling and mitral annular dilation, although some variability in the literature was present. Preexisting MR or ventricular dysfunction, elongated MV leaflets, and bilateral LTx procedure appeared to be risk factors for MR development. Management was dependent on the timing of MR and its pathophysiology, where systolic anterior motion–related MR was treated with medical therapy, whereas postoperative MR often required MV interventions. In conclusion, the diagnosis of MR in LTx patients is complicated by its symptomatic overlap with other post-LTx complications. Echocardiographic monitoring in patients with preexisting MR, regardless of severity, is essential for early identification and management. Further research is needed to better understand the underlying mechanisms and refine management strategies for MR in this population.

SUMMARY Advancements in neoadjuvant regimens for esophageal adenocarcinoma have enabled some patients to achieve complete pathologic response at time of esophagectomy. There are currently limited data detailing this trend or the implications of complete pathologic response on survival. The National Cancer Database was used to identify 16,169 patients with esophageal adenocarcinoma that received trimodal therapy including esophagectomy between 2006 and 2020. Of these, 11.4% had complete pathologic response at esophagectomy. Patient factors, staging characteristics, and survival trends were evaluated. In patients diagnosed between 2016 and 2020, the rate of complete pathologic response was 17.5%. Female sex (OR 1.295, 95% CI 1.134–1.481, p = 0.0001), Black race (OR 1.729, 95% CI 1.362–2.196, p = 0.0002), Hispanic ethnicity (OR 1.418, 95% CI 1.073–1.875, p = 0.0141), and later era of diagnosis (2016–2020 OR 2.898, 95% CI 2.508–3.349, p < 0.0001) were independent predictors of complete pathologic response. Clinical stage II disease was associated with an increased probability of complete pathologic response (OR 1.492, 95% CI 1.19–1.871) while clinical stage III disease had a decreased probability of complete pathologic response (OR 0.762, 95% CI 0.621–0.936, p < 0.0001). Complete pathologic response conveyed a strong survival benefit, with a median survival of 86.4 months (95% CI 73.9–102.1) versus 30.7 months (95% CI 29.8–31.7, p < 0.0001) in those without complete pathologic response. Four-year median survival was also higher in those with complete pathologic response (63.3%, 95% CI 60.8–66.0% vs. 39.2%, 95% CI 38.4–40.1%, p < 0.0001). In summary, complete pathologic response is associated with a profound survival advantage in patients with esophageal adenocarcinoma. Such knowledge carries implications for patient counseling, prognostication, and surveillance and demonstrates a need for improved identification of complete clinical response prior to esophagectomy.