Faculty Bibliography

BACKGROUND: The presence of an air leak is currently a contraindication for removal of a chest tube. The objective of this series was to evaluate the safety of chest tube removal in patients with an air leak. METHODS: This study was a retrospective cohort study of a prospective database. Patients who underwent elective pulmonary resection and were discharged home with a chest tube were eligible. RESULTS: Between July 2000 and July 2007, 6,038 patients underwent elective pulmonary resection by one general thoracic surgeon. One hundred and ninety-nine patients (3.8%) with a persistent air leak had their chest tubes placed to a suctionless portable drainage device and were discharged home. One hundred ninety-four patients (97%) returned to our clinic (median, postdischarge day 16). One hundred thirty-seven patients had no air leak, and 57 patients still had an air leak. All 137 patients (including 26 with a nonexpanding pneumothorax) had their chest tubes removed. In addition, all 57 patients (including 19 who had pneumothorax as well) had their chest tubes removed without sequela (9 after provocative clamping). At 3 months' follow-up, all patients were asymptomatic without evidence of pleural space problems, except 3 (all in the persistent air leak group) in whom an empyema developed. CONCLUSIONS: Patients with air leaks can be safely discharged home with their chest tubes. These tubes can be safely removed even if the patients have a pneumothorax, if the following criteria are met: the patients have been asymptomatic, have no subcutaneous emphysema after 14 days on a portable device at home, and the pleural space deficit has not increased in size.

OBJECTIVE: We evaluated our results from our prospective database to identify possible modifications that may improve our fast-tracking protocols in selected high-risk patients. METHODS: We conducted a retrospective study of a prospective database. Using multivariable regression, we identified several patient characteristic that predicted failure to fast-track owing to increased morbidity. We modified our fast-tracking algorithm by substituting pain pumps for epidurals in elderly patients (>70 years). In addition, patients with a body mass index greater than 35 had increased aspiration precautions. Patients with poor pulmonary function (ratio of forced expiratory volume in 1 second to forced vital capacity and/or diffusing capacity/alveolar volume < 45%) underwent increased respiratory treatments and more aggressive ambulation. Differences in outcomes between groups were compared after adjusting for differing baseline patient characteristics, including use of a propensity score. RESULTS: A total of 2895 patients underwent elective pulmonary resection before the algorithm modifications (January 1997-December 2001) and 3252 patients afterward (January 2002-July 2007) by one surgeon. The length of stay was reduced by the protocol changes from 6.7 to 4.9 days (P = .024) in elderly patients, from 5.7 to 4.8 days in obese patients, and from 6.2 to 4.3 days (P = .008) in those with poor pulmonary function. Morbidity was reduced from 26% to 17% in elderly patients (P = .046), from 29% to 20% (P = .027) in obese patients, and from 45% to 23% in those with poor pulmonary function. Overall mortality was also reduced 4.0% to 2.1% (P = .014). CONCLUSION: A prospective database provides important information that can lead to improvement in patient care by identifying specific complications. High-risk patients such as the elderly, the obese, and those with poor pulmonary function can safely undergo pulmonary resection and have a shorter hospital stay.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is an increasingly used technique to treat patients with pulmonary metastases, but it does not usually afford lung palpation. METHODS: A retrospective study on patients with lesions defined as 'VATA-able' who underwent open metastasectomy via thoracotomy. All patients underwent 64-slice helical CT scan with intravenous contrast using 5mm cuts and integrated FDG-PET/CT. Unsuspected malignant pulmonary nodules that were palpitated and removed, and were not imaged pre operatively were defined as 'malignant nodules' and would have been missed by VATS metastasectomy. RESULTS: From January 2004 to December 2005, 57 patients had 'VAT-able' metastatic pulmonary lesions that were resected via thoracotomy by one thoracic surgeon. Twenty-one (37%) patients had non-imaged pulmonary nodules that were discovered only by bi-manual palpation and would have been missed by VATS metastasectomy, but these nodules were only malignant in 10 (18%) patients. The median size of the non-imaged pulmonary nodule was 0.7cm (range, 0.4-0.8cm). Colorectal carcinoma was the most common tumor requiring metastasectomy. Non-imaged malignant pulmonary nodules were most frequently found in patients with leiyomyosarcoma and osteosarcoma (three of eight patients in both). CONCLUSION: Metastasectomy via open thoracotomy, which affords bi-manual lung palpation of the entire ipsilateral lung, may discover non-imaged malignant pulmonary metastases in 18% of patients who have had a previously treated solid organ cancer and have at least one imaged metastatic lesion in the lung. The clinical impact of these findings is unknown. A prospective study to further examine this issue is underway.

In contrast to the benign clinical course of a primary spontaneous pneumothorax, secondary pneumothorax in patients who have severe COPD can be a life-threatening event. COPD patients who develop spontaneous pneumothorax require a more aggressive management of their acute respiratory problem and treatment to prevent recurrences. All patients who have secondary spontaneous pneumothorax should be hospitalized and managed with tube thoracostomy and chest roentgenogram. Patients who have a persistent or large air leak or those who lack parietalto-visceral pleural apposition should undergo VATS early in their hospital stay. During VATS, the leaking bulla should be resected if it can be located, and if not, the most apical bleb should be resected. In addition, pleurodesis along with pleurectomy should be considered in those patients who are safe operative candidates. These techniques help prevent future pneumothoraces from bleb rupture in the patients who have COPD.

BACKGROUND: We have used doses of 60Gy or higher for neoadjuvant chemoradiotherapy for select patients with advanced non-small cell lung cancer (NSCLC), including patients with N2 disease and those with Pancoast lesions, to avoid gaps in radiotherapy in case surgery is ultimately not offered. METHODS: A retrospective cohort study using a prospective database. Patients underwent initial staging with CT, PET/CT and lymph node biopsy (mediastinoscopy, endoscopic esophageal ultrasound and endobronchial ultrasound) and then received neoadjuvant high dose radiotherapy and chemotherapy, followed by thoracotomy with intent to cure. RESULTS: Between January 1998 and June 2008 there were 216 patients who were eligible for this study. The median dose of radiation was 60Gy (range 60-72Gy). Lobectomy was performed in 152 patients (70%) about 7 weeks after radiotherapy finished (mean 51 days, range 34-89 days).The bronchus was buttressed with an intercostal muscle flap in 97% patients. Median hospital stay was 4.5 days (range 2-57). Major morbidity occurred in 17%. There were five (2.3%) deaths. There were no bronchial-pleural fistulas after lobectomy, but two occurred after right pneumonectomy. Predictors of morbidity were FEV(1) <50% (p<0.001), DLCO <60% (p<0.001) and age >75 years (p=0.008). The overall 5-year Kaplan-Meier survival was 34%. It was 42% for those who underwent R0 resection, 38% for those with initial N2 disease and 45% for the 71 complete responders. CONCLUSIONS: Pulmonary resection after high dose (>/=60Gy) neoadjuvant chemoradiotherapy is safe. Lobectomy can be safely performed and bronchopleural fistula prevented. Sixty Gy allows for maximal medical therapy in case resection is not offered. Since complete response rates may be higher than when 45Gy is used and since surgery is safe, its use deserves further investigation.