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.

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.

OBJECTIVE: The objective is to test the concept of "pay for performance" for patients with non-small cell lung cancer. METHODS: We constructed 53 benchmark performance standards (10 labeled "critical") and prospectively assessed the effect of adherence to these standards on morbidity and mortality for patients undergoing resection of non-small cell lung cancer. RESULTS: Between January 1, 2007, and December 31, 2009, 778 patients with non-small cell lung cancer underwent thoracotomy by 1 surgeon. Ninety-seven percent of patients received all 26 of the "day of surgery" and "intraoperative" benchmarks, and those were the easiest to deliver. The 469 patients who had all 53 benchmarks delivered, compared with the 309 who did not, had a lower mortality (2.0% vs 2.3%) and morbidity (16% vs 44%; P < .001). The 693 patients who received all 10 "critical" benchmarks, compared with the 85 who did not, had a lower mortality (1.9% vs 4.7%) and morbidity (25% vs 41%; P = .003). Low household income and fewer than 2 people in the household were predictors of overall morbidity on univariate analysis. CONCLUSIONS: Most benchmarks, especially "day of surgery" and "intraoperative" ones, can be delivered in more than 97% of patients. The delivery of benchmarks reduces perioperative morbidity but not mortality. Socioeconomic factors are predictors of overall morbidity. Operative mortality is related to the "quality of the patient" and the "quality of the health care provider."

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.

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.

PURPOSE: An endobronchial valve developed for treatment of severe emphysema has characteristics favorable for bronchoscopic treatment of air leaks. We present the results of a consecutive case series treating complex alveolopleural fistula with valves. DESCRIPTION: Patients with air leaks that persisted after treatment gave consent and compassionate use approval was obtained. Bronchoscopy with balloon occlusion was used to identify the airways to be treated. IBV Valves (Spiration, Redmond, WA) were placed after airway measurement. EVALUATION: During a 15-month period, 8 valve placement procedures were performed in 7 patients and all had improvement in the air leak. The median duration of air leakage was 4 weeks before and 1 day after treatment, with a mean of 4.5 days. Discharge within 2 to 3 days of the procedure occurred in 57% of the patients. A median of 3.5 valves (mode, 2.4) were used, and all valve removals were successful. There were no procedural or valve-related complications. CONCLUSIONS: Removable endobronchial valves appear to be a safe and effective intervention for prolonged air leaks.

BACKGROUND: EUS-guided FNA of the left and right adrenals has been described, but data are very limited. OBJECTIVES: Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement. STUDY DESIGN: Observational study. SETTING: Tertiary referral center. PATIENTS: Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach. RESULTS: Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 x 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (> or =30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered. LIMITATIONS: Lack of surgical criterion standard; 1 experienced endosonographer. CONCLUSIONS: EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.

BACKGROUND: The objective of this study was to assess the safety of general thoracic surgery in patients taking antiplatelet (clopidogrel) therapy. METHODS: A prospective study was conducted of consecutive patients who underwent general thoracic surgery and who were taking clopidogrel perioperatively. They were matched using a propensity score from our prospective database of 11,768 patients. Intraoperative and postoperative outcomes were compared. RESULTS: Between January 2009 and April 2010 there were 33 patients on clopidogrel at the time of surgery and 132 controls. The most common procedures were thoracotomy with lobectomy in 11 patients (robotic in 1), video-assisted wedge resection in 6, mediastinoscopy in 4, and Ivor Lewis esophagogastrectomy in 2. Epidurals were not used. There was no intraoperative morbidity or bleeding in primary thoracotomy; however, 2 of the 4 patients who underwent redo thoracotomy had bleeding that required transfusions. None of the 8 patients receiving clopidogrel who had a coronary artery stent and underwent lobectomy had a perioperative myocardial infarction whereas 5 of the 14 control patients undergoing lobectomy who had a coronary artery stent did (P = .05). Otherwise, morbidity, mortality, and length of stay were no different. CONCLUSIONS: Patients who are receiving clopidogrel and who have a coronary artery stent placed can safely undergo general thoracic surgery. The widely held belief that surgery cannot be performed without bleeding is untrue. This new finding not only eliminates much of the preoperative dilemma posed by these patients but also may reduce their risk of a postoperative myocardial infarction. However, patients who require a redo thoracotomy may be at increased risk of bleeding.