Faculty Bibliography

Lung cancer is the leading cause of cancer deaths worldwide and is responsible for more cancer deaths than the next three most common cancers combined. Despite common use of the best non-invasive tests for assessing clinical stage: computed tomography (CT) and integrated positron emission tomography/computed tomography (PET/CT) using 2-deoxy-2-18-fluoro-D-glucose (FDG), the pathologic stage is often different. The status of mediastinal (N2) lymph nodes is paramount in guiding therapy towards surgery, chemotherapy, radiotherapy or a combination of these modalities. Accurate staging is mandatory for patients prior to commencing therapy. Invasive tests that afford tissue biopsies of N2 lymph nodes are: esophageal ultrasound with fine needle aspiration (EUS-FNA), endobronchial ultrasound (EBUS-TBNA), and mediastinoscopy. This review article compares the two most commonly used invasive methods to obtain tissue biopsies of mediastinal (N2) lymph nodes: mediastinoscopy and endobronchial ultrasound (EBUS).

OBJECTIVE: Our objective is to assess the safety of a surgical technique applied to the difficult left upper lobectomy. The inflow-outflow occlusion technique features: dividing the superior pulmonary vein first, then proximal control by clamping the main pulmonary artery (PA), and then distal control by clamping the inferior pulmonary vein. METHODS: A retrospective cohort study of a prospective database was carried out. Patients who underwent left upper lobectomy and required clamping of the vessels were compared to those that did not. RESULTS: Between January 1999 and March 2010,1796 lobectomies were performed and 360 (23%) of these were left upper lobectomies. Of these, 84 (23%) required the inflow-outflow occlusion technique. There were 70 (83%) men (median age 65 years). Fifty-one patients (61%) required resection of the PA and 33 did not. Heparin was not used in the last 17 patients. These 84 patients were compared to the remaining 276 patients who underwent standard left upper lobectomy. Although the median operative time was longer (150 vs 105 min, p < 0.001) and the median blood loss was greater (120 vs 87 ml, p = 0.03) for the inflow-outflow technique, there were no significant differences in hospital length of stay, morbidity, or mortality between the two groups. CONCLUSION: In our experience, clamping of the inferior pulmonary vein instead of the distal PA achieves safe distal vascular control. It affords greater PA mobility and assessment of the tumor and easier PA repair. This technique can be used even when PA resection is not required.

Perioperative management of anticoagulants requires one to balance the patient's risk factors for operative bleeding, the type of operation to be performed, and the patient's risk of thromboembolism. At present, no set algorithm exists for the perioperative management of all the anticoagulants. In this article, we address the perioperative management of the most commonly used anticoagulants seen in practice today, such as warfarin, heparin, dabigatran, clopidogrel, and aspirin, for the most commonly performed general thoracic operations.

OBJECTIVE: To assess our results of a prospective algorithm applied to patients with thoracic esophageal perforation. METHODS: A retrospective review of a prospective algorithm. Patients with esophageal perforation underwent an esophagram. If there was a contained esophageal perforation they were admitted, kept nothing by mouth, and restudied in 3-5 days. If the leak was not contained, they underwent operative repair. RESULTS: From 1/1998 to 6/2009 there were 81 patients. The gastrograffin swallow showed 56 patients had contained perforations and 25 did not. Twenty-two of the 25 patients with noncontained perforation underwent immediate operative repair (one patient refused surgery, two were not stable enough for the operating room); their morbidity was 68% and there were six (24%) operative mortalities. Median hospital length of stay (LOS) was 11 days (range, 2-120). Of the 56 patients with contained perforations, 26 were managed successfully without surgery. However, 30 of the patients initially treated nonoperatively eventually required operations due to new pleural effusion, mediastinal abscess, or conversion to noncontained perforation. Their morbidity was 41% and there were three operative mortalities (5%). On univariate analysis, these patients were more likely to have undergone previous esophageal procedures (surgical or dilation) (p=0.03), had new or increased pleural effusion (p=0.04), and had greater than 24h between diagnosis and treatment (p=0.02). Only greater than 24h between diagnosis and treatment remained a significant predictor on multivariate analysis. Their median hospital LOS was 21 days (range, 7-77). CONCLUSION: Contained thoracic esophageal perforations can usually be safely managed nonoperatively without significant morbidity or mortality. However, careful in-hospital monitoring is needed if surgery is not chosen.

BACKGROUND: Many general thoracic surgeons are learning robotic pulmonary resection. METHODS: We retrospectively compared results of completely portal robot lobectomy with 4 arms (CPRL-4) against propensity-matched controls and results after technical changes to CPRL-4. RESULTS: In 14 months, 168 patients underwent robotic pulmonary resection: 7 had metastatic pleural disease, 13 had conversion to open procedures, and 148 had completion robotically (106 lobectomies, 26 wedge resections, 16 segmentectomies). All patients underwent R0 resection and removal of all visible lymph nodes (median of 5 N2, 3 N1 nodal stations, 17 lymph nodes). The 106 patients who underwent CPRL-4 were compared with 318 propensity-matched patients who underwent lobectomy by rib- and nerve-sparing thoracotomy. The robotic group had reduced morbidity (27% vs 38%; P = .05), lower mortality (0% vs 3.1%; P = .11), improved mental quality of life (53 vs 40; P < .001), and shorter hospital stay (2.0 vs 4.0 days; P = .02). Results of CPRL-4 after technical modifications led to reductions in median operative time (3.7 vs 1.9 hours; P < .001) and conversion (12/62 vs 1/106; P < .001). Technical improvements were addition of fourth robotic arm for retraction, vessel loop to guide the stapler, tumor removal above the diaphragm, and carbon dioxide insufflation. CONCLUSIONS: The newly refined CPRL-4 is safe and yields an R0 resection with complete lymph node removal. It has lower morbidity, mortality, shorter hospital stay, and better quality of life than rib- and nerve-sparing thoracotomy. Technical advances are possible to shorten and improve the operation.

Over the last 30 years neoadjuvant treatment of stage IIIA non-small cell lung cancer (NSCLC) followed by surgical resection for stage IIIB disease has significantly improved the overall results of treatment for patients with stage III NSCLC as well as for those with locally invasive tumors. Different chemotherapy regimens have been used, although in most studies some combination of drugs that include cisplatin is the standard. Radiation when given as part of the induction protocol appears to offer a higher rate of resection and complete resection, and higher doses of radiation are associated with better nodal downstaging. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial.

OBJECTIVE: Esophageal endoscopic ultrasound with fine needle aspiration (EUS-FNA) is a critical staging tool for patients with esophageal cancer. Previous reports suggest that it is frequently incorrect when it predicts a patient to be N0. The purpose of this study is to assess the efficacy of EUS-FNA in patients clinically staged N0. METHODS: A retrospective cohort study of patients who had a computed tomography scan, EUS-FNA and a positron emission tomography scan prior to undergoing Ivor Lewis esophagogastrectomy with abdominal and thoracic lymphadenectomy. RESULTS: From January 2002 to June 2009, 207 patients underwent Ivor Lewis esophagogastrectomy by one general thoracic surgeon. Ninety-five patients did not undergo neo-adjuvant therapy. Eighty nine of these patients had an EUS-FNA preoperatively and 82 were staged as N0. Seventy-seven (94%) were confirmed as N0 on final pathology (sensitivity 94%, accuracy 95%). Their overall 3-year Kaplan-Meier survival was 68%. Neo-adjuvant chemo-radiotherapy was given to the remaining 112 patients and 107 had a restaging EUS-FNA. Ninety of these patients were staged by EUS as N0. Seventy patients (78%) were N0 on final pathology (sensitivity 82%, accuracy 68%). There was no EUS-FNA-related procedural morbidity or mortality except for sore throat and nausea. CONCLUSION: EUS-FNA is very accurate and sensitive when it clinically stages patients with esophageal cancer as N0. In addition, it is even accurate and sensitive when restaging patients as N0 after neo-adjuvant chemo-radiotherapy. These results, which differ from previous reports, are critical for guiding treatment decisions.

OBJECTIVES: Our objective was to determine the long-term survival of patients with resected synchronous multiple pulmonary malignant tumors. METHODS: This is a multi-institutional retrospective study of patients who underwent surgical resection of synchronous (nonbronchioloalveolar) non-small cell lung cancer. RESULTS: Between March 1996 and December 2009, 67 patients (30 men) underwent 121 operations. Forty-four patients had bilateral tumors. Positron emission tomographic scans were performed in 58 (87%) patients, computed tomographic scans and magnetic resonance imaging of the brain in 53 (79%), and mediastinoscopy in 56 (84%). N2 lymph nodes were benign in all patients before undergoing resection of bilateral tumors of the same histologic type. Types of resection were lobectomy in 62, sublobar in 73, and pneumonectomy in 1. Eleven patients (16%) had postoperative morbidities. Cancer-specific 3- and 5-year survivals were 73% and 69%, respectively, and overall 3- and 5-year survivals were 64% and 53%, respectively. Subgroup analysis demonstrated no difference in overall survival at 5 years between bilateral tumors of the same histologic type (M1a) (49%) versus different histologic types 42% (P = .88), or between bilateral tumors (50%) and ipsilateral tumors (54%) (P = .83). CONCLUSIONS: The 5-year survival of surgically resected, synchronous, N2-negative, nonbronchioloalveolar, non-small cell lung cancer is excellent, even in patients who have bilateral lung lesions that harbor the same histologic features. Although the new TNM classification system labels this disease as clinical stage IV M1a, survival acts more like a separate T1 lesion after surgical resection. Thus, surgical resection should be considered in appropriately selected patients who have multiple pulmonary malignant tumors that are N2 negative.