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.

OBJECTIVE: Examination of factors that may contribute to racial disparity among those with lung cancer has been thwarted by heterogeneous treatment and staging strategies, limited national registry and socioeconomic and follow-up data. This study examines a decades worth of data to better elucidate these factors in a cohort staged or treated using homogeneous algorithms. METHODS: A nested case-control study of patients with non-small cell lung cancer (NSCLC). White patients were matched 4:1 to African American patients on age, gender, comorbidities, performance status, and stage. All patients underwent clinical and pathologic staging by one physician using similar staged-based treatment algorithms. Socioeconomic status was assessed by annual income per capita, insurance status, and education level. The primary outcome was survival rate. RESULTS: Among the 930 patients in this series, African Americans were more likely to be smokers (p < 0.001), have a lower per-capita annual income (p = 0.016), greater delay to treatment (p = 0.023), and less likely to agree to neo-adjuvant therapy (p < 0.001). Whites had better 5-year overall survival than African Americans for stage I (84% versus 78%, p = 0.037), stage II (52% versus 44%, p = 0.041), and stage III (32% versus 20%, p = 0.008) NSCLC. However, this survival advantage disappeared for earlier stages of NSCLC (I and II) when adjusted for socioeconomic status and smoking status. The survival advantage for stage IIIa was lost when adjusted for neo-adjuvant chemoradiotherapy. African American men had the worst survival of all subgroups independent of socioeconomic status. CONCLUSIONS: Given uniform staging, treatment, and socioeconomic status the overall survival rates for African American and White patients with NSLC are similar.

BACKGROUND: The pain of thoracotomy may be related to trauma to the intercostal nerves. METHODS: This was a prospective randomized study of 160 patients. All patients had a functioning epidural, similar type and size thoracotomy, an intercostal muscle flap (ICM) harvested before rib spreading, inferior rib drilling, and postoperative pain management. In one group, the ICM was left intact distally and it dangled (D group); the ICM in the other was cut distally (C group). Pain was assessed using multiple pain scores. Outcomes assessed were qualitative and quantitative pain scores, number of ribs broken, spirometric values, analgesic use, and return to baseline activity for postoperative days 1 to 5 and weeks 2, 3, 4, 8, and 12. RESULTS: The D group had 85 patients and the C group, 75. The groups had similar demographics, types of procedures, and histology. Intrahospital pain scores were similar; however, at postoperative weeks 3, 4, 8, and 12, the D group had significantly lower mean numeric pain scores and was using fewer analgesics (p < 0.05 for all). At 12 weeks, patients in the D group were more likely to have returned to baseline activity (p = 0.002). CONCLUSIONS: An ICM flap reduces pain. Harvesting and then leaving the ICM flap intact instead of cutting it before rib spreading further reduced thoracotomy pain. This technique, when added to rib drilling, leads to reduced pain on postoperative weeks 3 to 12, to quicker return to baseline activity, and lessens the need for analgesics.

BACKGROUND: Subcutaneous emphysema (SE) after pulmonary resection is troublesome and has been poorly studied. METHODS: A retrospective review was made of a prospective database. Patients who underwent pulmonary resection and in whom clinically detected SE were studied. RESULTS: Of 4,023 patients between January 1999 and June 2006, 255 patients (6.3%) had clinically apparent SE. Predictors of developing SE by multivariate analysis were preoperative forced expiratory volume of air in 1 second (FEV(1)%) less than 50%, having an air leak, and having had a previous thoracotomy. Despite maximizing chest tube suction, 85 patients (33%) had recalcitrant SE. These patients with recalcitrant SE were more likely to have a lower median FEV(1)% (p = 0.037), a previous ipsilateral thoracotomy, and have undergone a lobectomy (p < 0.001). Recently, 64 of the 85 patients underwent single-incision, video-assisted thorascopic surgery with pneumolysis and chest tube placement, which successfully resolved the SE within 24 hours in all patients except 1. These 64 patients had a significantly shorter hospital stay (6 versus 9 days, p = 0.02) and less time with recalcitrant SE than the other 21 patients. CONCLUSIONS: Subcutaneous emphysema is more likely in patients who have an FEV(1)% less than 50% and who undergo a redo thoracotomy. Recalcitrant SE emphysema (SE that persists despite increasing chest tube suction) is more likely in patients who undergo lobectomy and is best treated by video-assisted thorascopic surgery with pneumolysis between the leaking lung, which is usually partially adhered to the previously opened intercostal space. This directs the air leak back into the pleural space and out of the subcutaneous space. This procedure shortens the duration of SE and hospital stay.

BACKGROUND: The purpose of this study was to investigate differences in epidemiology, types of presentation, time between diagnosis and treatment, tumor characteristics, and survival in patients 45 years or younger with non-small cell lung cancer. METHODS: A nested case-control study was conducted during 7 years using a prospective database of patients with non-small cell lung cancer. Younger patients (<45 years of age) were matched 1:2 with older patients for stage, sex, performance status, and type of resection. RESULTS: There were 762 patients (254 were <45 years old, 508 controls were older). The median time from initial symptom to thoracic surgical consultation was significantly longer for those younger than 45 years (6.5 versus 2.8 weeks; p < 0.001). Younger patients were more likely to be symptomatic at the time of diagnosis (89% versus 68%; p < 0.001) and less likely to be smokers (45% versus 78%; p < 0.001). Kaplan-Meier analysis showed the time between diagnosis and treatment, symptoms, maximum standardized uptake value on positron emission tomography, and smoking status impacted survival. Only symptoms and smoking status impacted survival on Cox proportional hazards survival analysis among completely resected patients; 5-year survival was lower in the younger group compared with the older group (51% versus 62%; p = 0.037). CONCLUSIONS: Despite similar stages and tumor characteristics patients younger than 45 years of age with non-small cell lung cancer have a significantly worse prognosis than older patients. Although they are more likely to be symptomatic, younger patients have a greater delay in seeking thoracic surgical care. These data should be considered in the treatment strategy offered to younger patients with non-small cell lung cancer.