Faculty Bibliography

Understanding the anatomy of the lymphatic channels and lymph nodes in the mediastinum is relevant to many disease processes as well as therapeutic interventions for thoracic malignancies. A brief review of the anatomy of the mediastinal lymph nodes is presented and the indications for mediastinal lymph node dissection are discussed, followed by a more detailed description of the technical aspects of thoracoscopic and robotic mediastinal lymph node dissection.

OBJECTIVES: We evaluated factors that influenced morbidity and mortality in patients undergoing completion pneumonectomy (CP). METHODS: A retrospective review of a consecutive series of patients who underwent CP at six international centres. RESULTS: In total, 165 CP were performed between March 1990 and December 2009: 152 for malignant disease and 13 for benign disease. Forty-two patients (25.4%) underwent neoadjuvant therapy. Right CP was performed in 99 patients (60%) and left in 66 (40%). Thoracotomy was employed in 161 patients and median sternotomy in 4. Stapled closure of the bronchus was performed in 121 patients and hand closure in 44. The overall operative mortality was 10.3% (17 of 165). Operative mortality was 10.5% (16 of 152) in malignant diseases and 7.7% (1 of 13) in benign diseases. Complications occurred in 55.1% (91 of 165) of patients. Mean hospital stay was 16.02 +/- 16.8 days (range: 3-151 days). Thirteen patients (7.9%) developed bronchopleural fistulas. No statistically significant relationship was found in mortality or morbidity according to side, gender, induction therapy and surgical approach. Stapled compared with hand closure for the bronchus did not affect the bronchopleural fistula rate (P = 0.4). The overall 5-year survival was 37.6%: 70.1% in benign disease (13 patients), 48.9% in squamous cell carcinoma of the lung (63 patients), 23.9% in primary lung adenocarcinoma (62 patients), 50% in grade 1 and grade 2 neuroendocrine carcinoma of the lung (4 patients), 54.7% in metastatic disease (14 patients) and 0% in primary lung sarcomas. A statistically significant better survival was observed in patients with squamous cell carcinoma versus adenocarcinoma (P = 0.04). CONCLUSIONS: CP shows an acceptable operative mortality with a high morbidity rate. The overall 5-year survival is acceptable in properly selected patients (i.e. squamous cell carcinoma, metastatic disease). Side, gender, induction therapy and surgical approach did not influence mortality and morbidity.

OBJECTIVES: We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion. METHODS: After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes. RESULTS: Forty-two patients with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. Twenty-nine patients (69%) had ovarian cancer. Fifty-seven percent had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. Eight patients (19%) underwent perioperative VATS to improve pulmonary status. Seven patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1-53). Sixty-two percent had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300-4500), and the majority (88%) of patients had a talc pleurodesis performed. Seven patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS. One patient was readmitted with hospital-acquired pneumonia and died during readmission. Median time to death after VATS was 104 days (range 4-1062). Patients who underwent a perioperative VATS had the longest survival (845 days). CONCLUSION: Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.

OBJECTIVE: Thoracic surgeons are performing robotic resections for anterior mediastinal tumors; however, tumors located in the posterior and especially the inferior chest can be difficult to approach robotically. The objective of this study was to evaluate the efficacy of the robot for resection of these tumors. METHODS: We performed a retrospective review of the evolution and outcomes of our surgical technique for inferior or posterior mediastinal pathology. RESULTS: During a 30-month period, 153 patients underwent robotic surgery for pathology in the mediastinum, located in the inferior or posterior mediastinum in 75 of these patients. The most common indications for surgery were posterior mediastinal mass or lymph node in 41 patients, esophageal or bronchogenic cysts in 11 patients, esophageal leiomyoma in 7 patients, and diaphragmatic elevation in 7 patients. The median tumor size was 4.4 cm, and the median length of stay was 1 day. One patient was converted to thoracotomy, but no patients were converted for bleeding. Morbidity occurred in 9 patients (12%), major in 1 patient (a delayed esophageal leak after epiphrenic diverticulectomy). There was no mortality. Technical improvements included using robotic arm 3 posteriorly for retraction, side-docking, or coming over the back of the patient for tumors inferior to the inferior pulmonary vein and for diaphragmatic plication and using the lateral decubitus position for extraction of tumors larger than 3 cm via an access port over the tenth rib above the diaphragmatic fibers. CONCLUSIONS: The robot affords safe access using a completely portal approach for resection of and surgical intervention for inferior and posterior chest pathology and for anterior tumors. Specific techniques can be used to improve the operation.

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.

The present project involved a collective effort agreed by the European Society of Thoracic Surgeons, the American Association for Thoracic Surgery, the Society of Thoracic Surgeons, and the General Thoracic Surgery Club to assemble a joint panel of experts to review the available data and address ambiguous aspects of chest tube definitions and nomenclature. The task force was composed of 11 invited participants, identified for their expertise in the area of chest tube management. The subject was divided in different topics, which were in turn assigned to at least two experts. The draft reports written by the experts on each topic were distributed to the entire expert panel, and comments solicited in advance of the meetings. During the meetings, the drafts were reviewed, discussed, and agreed on by the entire panel. Standardized definitions and nomenclature were proposed for the following topics related to chest tube management: pleural and respiratory mechanics after pulmonary resection; external suction versus no external suction; fixed versus variable suction; objective air leak evaluation; objective fluid drainage evaluation; and chest drain: type, number, and size. A standardized set of definitions and nomenclature were proposed to set a scientifically based framework with which to evaluate existing studies and to more clearly formulate questions, parameters, and outcomes for future studies.

BACKGROUND: The purpose of this study is to assess the clinical benefit of performing a daily chest roentgenogram (CXR) on patients who have had a pulmonary resection. METHODS: Patients underwent thoracotomy and pulmonary resection, and all had a daily CXR. The impact the CXR had on their care was evaluated. Hypoxia was defined as a sustained decrease in oxygen saturation of 6% or greater from patient's baseline. RESULTS: Between January 2006 and December 2009, 1,037 patients met the eligibility criteria for this study. Types of resection were wedge in 282 patients, segmentectomy in 146, and lobectomy in 609. Only 20 of the 834 patients (2%) who did not have a pneumothorax on the recovery room CXR had hypoxia, compared with 42 patients (21%) who had a recovery room pneumothorax (odds ratio 10.6, 95% confidence interval: 6.1 to 18.5, p<0.001). Daily CXR changed the care of only 268 of 975 patients (27%) who never had hypoxia compared with 49 of the 62 patients (79%) who were hypoxic (odds ratio 9.2, 95% confidence interval: 4.3 to 13.7, p<0.001). Moreover, the changes in care made by the CXR in the 268 nonhypoxic patients were for small pneumothoraces, and the impact of these changes is dubious. CONCLUSIONS: Daily CXRs are not needed in the vast majority of patients who undergo elective pulmonary resection after thoracotomy. It is of little benefit for patients who do not have a pneumothorax on their recovery room CXR or for patients who do not become hypoxic.

BACKGROUND: To prospectively assess the incidence of non-imaged malignant nodules in patients who undergo thoracotomy for metastasectomy with bimanual lung palpation. METHODS: This is a prospective cohort study of patients who underwent open metastasectomy by thoracotomy. All patients had metastatic lung lesions, underwent 64-slice helical computed tomographic (CT) scan with intravenous contrast using 5-mm collimated cuts, and most had integrated PET (positron emission tomography)-CT. Unsuspected malignant pulmonary nodules that were palpated and removed, and that were not imaged preoperatively, were recorded. RESULTS: From January 2006 to March 2010, 152 patients underwent metastasectomy by rib-sparing, nerve-sparing thoracotomy by 1 surgeon. Fifty-one (34%) patients had 57 pulmonary nodules that were not imaged preoperatively and 32 of the 57 (56%) nodules were malignant. Thirty patients had non-imaged malignant nodules that were palpated and removed. There were 15 malignant nodules that were in different lobes than the imaged nodules. The 3 most commonly missed malignant nodules occurred in patients with colorectal cancer, renal cell, and sarcoma. CONCLUSIONS: Metastasectomy by thoracotomy, which affords bimanual palpation of the entire lung, discovers ipsilateral non-imaged malignant pulmonary metastases in 1 of 5 patients who had at least 1 imaged metastatic pulmonary lesion. This is true despite preoperative, fine cut chest CT scan with contrast, and integrated 18F-fluorodeoxyglucose-PET-CT scanning. The clinical significance of these non-imaged, resected malignant nodules is unknown, nor is the added morbidity of resecting benign nodules.