Faculty Bibliography

Air leaks are one of the most common complications after pulmonary resection and they are the most frequent cause of prolonged hospital stay, increased cost and patient dissatisfaction. The management of chest tubes in patients with air leaks is optimized when the air leak is scientifically evaluated. The traditionally used analogue classification system, the Robert David Cerfolio Classification System (or RDC named after my father) has inherent subjectivity to it and may be interpreted differently by different bedside observers. More recently, several companies have developed digital pleural drainage systems that are able to quantify the size of air leaks in ml/min or in ml/breath. This eliminates the subjectivity. This affords better interpretation of chest tube setting changes and of air leak healing. These units also provide recordings of the air leak and of the pleural pressure. In this multimedia chapter, we report the different methods of measuring air leaks.

OBJECTIVES: With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS. METHODS: All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded. RESULTS: A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01-0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure. CONCLUSIONS: CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.

Recent studies have shown that patients who are down-staged via neoadjuvant therapy and undergo resection have a significant increased 5-year survival rate (as high as 40%-50%) when compared with patients who have residual N2 disease. The identification of patients who are N2 negative after the completion of their neoadjuvant therapy is a critical component of proper patient selection for thoracotomy. Some may even argue that it is a necessary step before resection. In this article we review the best ways to restage patients with N2 disease after they have completed their neoadjuvant therapy.

BACKGROUND: Stage IIIA non-small cell lung (NSCLC) from N2 disease is common, but represents a heterogeneous group of patients. Predictors of who completes their neoadjuvant chemoradiotherapy and undergoes subsequent surgical resection are unknown. METHODS: This retrospective cohort study used a prospective database. Patients who had biopsy-proven, nonbulky N2 disease underwent neoadjuvant chemoradiotherapy and were restaged or resected, or both. RESULTS: There were 402 patients, and 326 (81%) completed their neoadjuvant therapy. Only 198 (50%) returned for definitive pathologic restaging, and 149 (37%) underwent thoracotomy for attempted resection. Predictors of who returned to the surgical arena were age (< 70), multiple node involvement, and response to neoadjuvant therapy. The 5-year survival was 8% for the 253 patients who did not return for restaging but was 47% for the 149 patients who underwent thoracotomy (p < 0.001). The 5-year survival for selected subgroups of patients who underwent complete resection was 42% for the 14 patients who had unsuspected recalcitrant N2 disease, 49% for the 65 patients who had a partial response, and 53% for the 34 patients who had a complete response. CONCLUSIONS: Only 37% of patients with favorable, nonbulky, biopsy-proven N2 disease actually complete their neoadjuvant therapy, undergo restaging, and then return for attempted resection. Only 28% undergo complete resection. However, in this highly selected subset of patients, the 5-year survival is 47% or better if partial or complete pathologic response is achieved. Therefore, surgical resection remains a viable treatment for selected patients with favorable N2 NSCLC.

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital LOS and reduce costs for patients. who undergo both open and VATS procedures The ability to fast-track is not governed by the type of procedure (closed versus open), but rather by patient characteristics and the mindset of the operating surgeon and the postoperative care team. While use of protocols enhance the ability of many physicians to fast-track many different types of patients, it is a mistake to force these protocols on all patients because, if not modified, they can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results using accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Specific changes to the postoperative algorithms can be implemented and these alterations can lead to improved outcomes. For example, we have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high patient satisfaction. We have also shown that the use of increased physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those with low FEV1% and DLCO%. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient and cost-saving care by way of preset postoperative algorithms after VATS or thoracotomy procedures. When the typical daily events are communicated each morning and the planned date of discharge is reinforced with the patient and family before surgery and each day in the hospital on rounds, most patients can be safely fast-tracked with high satisfaction and outstanding results.

BACKGROUND: Air leaks remain the most common pulmonary complication after elective pulmonary resection, yet their assessment, unlike other clinical bedside indicators, remains analogue and not digital. METHODS: This prospective randomized study compared a digital air leak system with the current analogue air leak system in 100 patients that underwent elective pulmonary resection. RESULTS: The digital and analogue patient groups each had 50 patients. Pulmonary function, types of pulmonary resection, number of chest tubes, and pathology were not statistically different between the groups. The digital system confirmed the air leak status in 5 patients that were equivocal on the analogue system. The ability to assess the air leak status continuously afforded quicker chest tube removal in the digital group (mean, 3.1 vs 3.9 days, p = 0.034) and reduced hospital stay (mean, 3.3 vs 4.0 days, p = 0.055). Three patients were discharged home with the device, without complications. CONCLUSIONS: The digital and continuous measurement of air leaks instead of the currently used static analogue systems reduces hospital length of stay by more accurately and reproducibly measuring air leaks. This leads to quicker chest tube management decisions because the average size of an air leak during the last several hours can be determined. Intrapleural pressure curves may also help predict the optimal chest tube setting for each patient's air leak and eliminate the need for chest roentgenograms. Further studies on the pleural pressure curves and this device are needed.

BACKGROUND: The objective of this study was to determine the survival of patients who have completely resected, nonsmall-cell, stage IIIA, lung cancer from unsuspected (nonimaged) N2 disease who received adjuvant chemotherapy. METHODS: This is a retrospective cohort study using a prospective database. All patients underwent positron emission tomography scan and computed tomography scan with contrast, R0 resection with complete thoracic lymphadenectomy, and had unsuspected, pathologic N2 NSCLC. RESULTS: Between June 1998 and December 2007, there were 148 patients (89 men). The most common pulmonary resection was right upper lobectomy in 67 patients (48%), and the most common lymph node station for unsuspected N2 diseased was 4R. One hundred and thirty-seven patients (93%) received adjuvant chemotherapy and 13% received postoperative radiation as well. The overall 2- and 5-year survivals were 58% and 35%, respectively. The 5-year survival for the 98 patients with single lymph node disease compared with patients with multiple nodal involvement was 40% versus 25%, respectively (p = 0.028). The number of lymph nodes involved (p = 0.032) was an independent predictors of survival on multivariate analysis. Median follow-up was 54 months. CONCLUSIONS: The 5-year survival of patients with unsuspected N2 disease who undergo complete resection, followed by adjuvant therapy, is 35%. Patients with single station N2 disease fare better. The role for mediastinoscopy, endoscopic esophageal ultrasound with fine-needle aspirate, or endobronchial ultrasound in patients who are negative by positron emission tomography and computed tomography is unknown, since the benefit of neoadjuvant therapy in these patients is also unproven. A randomized study is needed.