Faculty Bibliography

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.

OBJECTIVE: The objective was to identify whether repeat positron emission tomography scan after neoadjuvant chemoradiotherapy in patients with esophageal cancer predicted a complete response. METHODS: A retrospective study using a prospective database was performed. Patients had esophageal cancer and underwent neoadjuvant chemoradiotherapy, an initial and repeat positron emission tomography, endoscopic ultrasound with fine-needle aspiration (at the same institution), and Ivor Lewis esophagogastrectomy with lymph node resection. RESULTS: There were 221 patients who underwent Ivor Lewis, 86 of whom had their initial and repeat positron emission tomography scans performed at the same center. Of these, 37 patients (43%) were complete responders. The median maximum standardized uptake value of esophageal cancer decreased by 72% in the 37 patients who were complete responders, by 58% in the 31 patients who were partial responders, and by 37% in the 18 patients who had a minimal pathologic response. When the maximum standardized uptake value decreased by more than 64%, the patient was likely to be a complete responder (P = .003, area under the curve = 0.75). CONCLUSION: When initial and repeat positron emission tomography scans are performed at the same center at least 30 days after the completion of preoperative chemoradiotherapy, the percent change in the maximum standardized uptake value is a predictor of the response to chemoradiotherapy by a patient with esophageal cancer. When the maximum standardized uptake value decreases by 64% or more, it is likely that the patient is a complete responder. These data may help guide neoadjuvant therapy and identify patients for a future randomized study that compares observation with surgical resection in patients with esophageal cancer who appear to be complete responders.

BACKGROUND: The optimal management of the pylorus during esophagogastrectomy is unknown. Pyloromyotomy and pyloroplasty cause early edema and risk long-term bile reflux; however, the lack of pyloric drainage might risk early aspiration. METHODS: We performed a retrospective study with a prospective database on patients with esophageal cancer or high-grade dysplasia who underwent Ivor-Lewis esophagogastrectomy. All had one surgeon and similar stomach tubularization, hand-sewn anastomoses, nasogastric tube duration, and postoperative prokinetic agents. Outcomes of postoperative gastric emptying, aspiration, and swallowing symptoms were compared. RESULTS: Between January 1997 and June 2008, there were 221 patients. Seventy-one patients had a pyloromyotomy, and gastric emptying judged on postoperative day 4 was delayed in 93% (52% had any morbidity and 14% had respiratory morbidity). Fifty-four patients had no drainage procedure, and gastric emptying was delayed in 96% (59% had any morbidity and 22% had respiratory morbidity). Twenty-eight patients underwent pyloroplasty, and 96% had delayed gastric emptying (50% had any morbidity and 32% had respiratory morbidity). Sixty-eight patients had botulinum toxin injection into the pylorus. Gastric emptying was delayed in only 59% (P = .002, 44% had any morbidity and 13% had respiratory morbidity). Hospital length of stay (P = .015) and operative times (P = .037) were shorter in the botulinum toxin group. Follow-up (mean, 40 months) showed symptoms of biliary reflux to be lowest in the botulinum toxin group (P = .024). CONCLUSION: Injection of the pylorus with botulinum toxin at the time of esophagogastrectomy is safe and decreases operative time when compared with pyloroplasty or pyloromyotomy. In addition, it can improve early gastric emptying, decrease respiratory complications, shorten hospital stay, and reduce late bile reflux. A prospective multi-institutional randomized trial is needed.