Faculty Bibliography

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.

BACKGROUND: Accurate false negative rates for endobronchial ultrasound (EBUS) and esophageal ultrasound (EUS) for mediastinal (N2) lymph nodes are unknown. METHODS: A retrospective review of patients with non-small cell lung cancer (NSCLC) underwent integrated positron emission tomography and computed tomography (PET/CT) and CT scan. All suspicious N2 lymph nodes were biopsied before thoracotomy. The EBUS was performed for suspicious nodes in stations 2R, 4R, 4L, 5, and 7; the EUS was performed for 4L, 4R, 5, 7, 8, and 9. Mediastinoscopy was performed in selected patients if they were negative by EUS/EBUS; if N2 negative, all patients underwent thoracotomy with complete thoracic lymphadenectomy. RESULTS: There were 425 patients over a 2-year period, and 234 had suspected N2 disease. Of these patients, 72 had an EBUS; 16 were positive for N2 disease and 12 were false negative (7 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 57%, negative predictive value 79%, accuracy 83%). Seventy-nine patients had EUS; 20 patients were positive for N2 disease and 12 were false negative (4 patients at station 4R/4L, 4 patients at station 7; patient sensitivity 63%, negative predictive value 80%, accuracy 85%). One hundred and forty-six patients had mediastinoscopy, which revealed N2 or N3 disease in 42 patients, and 7 were false negative (patient sensitivity 88%, negative predictive value 93%, accuracy 95%). CONCLUSIONS: Both EBUS and EUS are useful initial tests to biopsy suspicious N2 mediastinal lymph nodes; however, as EBUS and EUS have high false negative rates, especially at stations 4R and 7, mediastinoscopy is still required for patients with suspicious nodal disease in these stations.

Recently, several companies have manufactured and commercialized new pleural drainage units that incorporate electronic components for the digital quantification of air through chest tubes and, in some instances, pleural pressure assessment. The goal of these systems is to objectify this previously subjective bedside clinical parameter and allow for more objective, consistent measurement of air leaks. The belief is this will lead to quicker and more accurate chest tube management. In addition, some systems feature portable suction devices. These may afford earlier mobilization of patients because the pleural drainage chamber is attached to a battery-powered smart suction device. In this article we review the clinical experiences using these new devices.

Most patients who undergo pulmonary resection can have one chest tube and have it removed by postoperative day 3. Air leaks are probably best treated with water seal (passive suction) for most patients with small leaks. If they develop a new or enlarging pneumothorax or subcutaneous emphysema, some suction (active suction) is needed and alternating suction at night with waters seal during the day may be best. Most patients with persistent air leaks can be discharged home safely on an outpatient device and have their tubes removed in 2 to 3 weeks even if they still have an air leak.

BACKGROUND: Photodynamic therapy is a nonthermal laser used for obstructive, bloody lesions in the airway. METHODS: A retrospective cohort study of a prospective database was conducted. All patients underwent rigid and flexible bronchoscopy under general anesthesia using jet ventilation. RESULTS: There were 529 operations performed on 133 patients between January 1996 and December 2008. The mean preoperative Modified Medical Research Council Dyspnea Scale grade was 3 of 4. Indications for intervention were non-small cell lung cancer in 89 patients, metastatic airway lesions in 31 patients, small cell disease in 4 patients, benign disease in 7 patients, other or unknown in 2 patients. Tumors were most commonly located in the main stem bronchi (71 patients). A 2.5-cm diffuser was used in 87% of patients, and 300 J (range, 50 to 300 J) was most frequently selected at first treatment. Most patients received two treatments during a 3-day hospitalization and returned in 2 weeks for two more photodynamic therapy treatments. The mean postoperative Modified Medical Research Council Dyspnea Scale grade was 2.7 of 4 and improved in 94 patients (74%). There were 12 operative mortalities (none treatment related). Morbidity occurred in 20 patients (reintubation in 4 patients and respiratory distress leading to an emergent evacuation of debris in 2 patients). Only 4 patients had a photosensitivity reaction. CONCLUSIONS: Photodynamic therapy is a safe and effective treatment. It is best used for bloody tumors that block the tracheobronchial tree, even in severely debilitated patients with profound shortness of breath from advanced malignancy who fail conventional core-out or laser treatments. Photosensitivity reactions are rare with proper education, and dyspnea is improved in properly selected patients.

BACKGROUND: The 30-day operative mortality rate after thoracotomy is well documented; however, the 90-day mortality rate is not and is not part of The Society of Thoracic Surgeons database. METHODS: We performed a retrospective cohort study using a prospective database of patients who underwent elective thoracotomy and pulmonary resection. Mortality rates were compared with The Society of Thoracic Surgeons database. Multivariate analysis was used to identify predictors of mortality after discharge but within 30 and 90 days. RESULTS: There were 1,845 operative patients between January 2002 and December 2008. Mortality was defined several ways. The overall discharge mortality was 3.1%; however, 18 patients (1.0%) died after discharge within 30 days and 44 patients (2.5%) died between 31 and 90 days. Sudden death (usually because of a cardiac event) was the most common cause of death in patients after discharge before postoperative day 30 and the second most common cause in those who died after discharge between days 31 and 90. These patients were more likely to have advanced age (p = 0.004), history of hypertension (p = 0.013), and coronary artery disease (p < 0.001). CONCLUSIONS: A significant number of patients die after discharge within 90 days after pulmonary resection. The most common causes of death at home are "sudden death" and are more common in patients with a history of coronary artery disease. These patients may benefit from more diligent postoperative care. A prospective database with calls to patients and families is required to accurately obtain this information and to establish true outcomes. The Society of Thoracic Surgeons database as well as nonsurgical databases that show efficacies of medical therapy for specific ailments should consider adding 90-day mortality results.

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.