Faculty Bibliography

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.

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.

BACKGROUND: We report our experience in starting a robotic program in thoracic surgery. METHODS: We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients. RESULTS: Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes. CONCLUSIONS: Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed.