Faculty Bibliography

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.

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.

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.

This article covers the risk factors, diagnostic tools, staging methods/modalities and treatment for patients with non-small cell lung cancer (NSCLC). Also presented is the new 7th edition American Joint Cancer Committee (AJCC) TNM classification for staging of NSCLC and a recommended treatment algorithm.

BACKGROUND: Neoadjuvant chemotherapy or chemoradiotherapy increases the risk of pulmonary resection. Changes in specific pulmonary function tests may be predictive. METHODS: A retrospective review of a prospective database of patients with non-small cell lung cancer who underwent neoadjuvant therapy, had pulmonary function tests performed both before and after therapy, and then underwent elective pulmonary resection was performed. Final values and change in the pulmonary function tests before and after treatment were entered as independent variables into a multivariate model in which the dependent variable was major or respiratory morbidity. RESULTS: There were 132 patients. The mean duration between pretherapy and posttherapy pulmonary function tests was 4.1 months. The mean change in the percent forced expiratory volume in 1 second, in the percent diffusion capacity of the lung for carbon monoxide, and in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume was +1.0, -6.4%, and -6.6%, respectively. Fifty-five patients (42%) experienced a postoperative complication, and 39 of those patients experienced a major or respiratory complication. There were 7 (5.3%) operative mortalities (5 were respiratory related). On multivariate analysis the change in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume was the only factor associated with major or respiratory morbidity (p = 0.028). When the posttherapy percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume fell by 8% or more, there was an increased likelihood of major morbidity (p = 0.01). CONCLUSIONS: A decrease in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume after neoadjuvant chemotherapy or chemoradiotherapy may predict increased risk for pulmonary resection, especially if the decrease is 8% or greater. These results should be considered in the preoperative risk assessment of patients who are to undergo pulmonary resection after induction therapy.

BACKGROUND: Many patients with resected, pathologic (p)stage I non-small cell lung cancer (NSCLC) are not adequately staged preoperatively or intraoperatively. Reported 5-year survival is about 65%. Recently, nonsurgical techniques are being offered to these patients. METHODS: A prospective database was retrospectively reviewed. All patients had an integrated positron-emission tomography/computed tomography (CT) and CT scan, an R0 pulmonary resection with lung palpation, and complete thoracic lymphadenectomy. RESULTS: From August 2002 until July 2008, 2171 patients presented with presumed, resectable NSCLC. Of these, 721 were clinically (c)staged I, and 1450 were (c)staged II, III, or IV. Of the 721 (c)stage I, 405 (56%) had (p)stage I disease; 101 (14%) were clinically over-staged (benign nodules). Of those with NSCLC, 32% were clinically under-staged (stage II or higher on path). The 5-year Kaplan-Meier survival rates were 80% for (p)stage IA, 72% for (p)stage IB (p = 0.026), and 87% for the 721 with (c)stage I disease. The median-follow up was 3.8 years. CONCLUSIONS: When patients with NCSLC are accurately staged preoperatively and undergo complete thoracic lymphadenectomy, the 5-year survival is 80% for (p)stage IA tumors and 87% for (c)stage I disease. About 32% of patients are under-staged (most commonly from nonimaged N2 disease) despite the liberal application of all of the techniques that assess mediastinal lymph nodes preoperatively. Thus surgical intervention offers improved staging with resection of unsuspected nodal or parenchymal disease. If stereotactic radiation and radiofrequency ablation are considered for patients with clinically staged I NSCLC, these results should be considered.

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: The percent predicted diffusing capacity of the lung for carbon monoxide (Dlco%) is an important pulmonary function test (PFT) obtained before elective pulmonary resection. However, there are several Dlco values reported and it is unknown which ones are important predictors of postoperative morbidity. METHODS: This is a retrospective study of a prospective database of patients who underwent PFTs and pulmonary resection by one surgeon. The PFTs evaluated were as follows: forced expiratory volume in one second (FEV(1)%), minute ventilation volume (MVV%), and three types of diffusion capacity of the lung for carbon monoxide values: the diffusion capacity of the lung for carbon monoxide (Dlco%), the Dlco adjusted for hemoglobin (DL adjusted%), and the Dlco adjusted for alveolar volume (Dlco/VA%). RESULTS: There were 906 patients between January 2005 and December 2007, and lobectomy was performed most commonly. Complications occurred in 254 patients (28%) and were respiratory in 115 (13%). On univariate analysis, age (p < 0.001), number of cigarettes smoked (p = 0.008), history of coronary artery disease (p = 0.028), FEV(1)% (p = 0.021), postoperative predicted (ppo) FEV1% (p < 0.001), Dlco% (p = 0.018), ppoDlco% (p = 0.002), and Dlco/VA% (p = 0.004) were significantly different among those who did and did not experience postoperative respiratory morbidity. Multivariate regression analysis identified ppoDlco%, ppoFEV1%, Dlco/VA%, and age as significant independent predictors of respiratory morbidity. Operative mortality was 2% (18 patients). CONCLUSIONS: Although age, FEV(1)%, ppoFEV(1)%, Dlco%, and ppoDlco% are all well-known predictors of operative morbidity after elective pulmonary resection, the Dlco/VA% is another important predictor. This information should be included to help guide patient selection for pulmonary resection and to determine preoperative risk stratification.